By Alan Katz, Associate Director of Advocacy & Public Policy, Civitas Networks for Health
ABSTRACT— During the COVID-19 pandemic, the California Department of Public Health (CDPH) developed a disease-specific network for laboratory test reporting in real time to operate alongside established clinical registries. The benefits of the new reporting system were evident—as was the need to expand and refine its capabilities for a new paradigm of post-pandemic health data functionality. The resulting Surveillance and Public Health Information Reporting and Exchange (SaPHIRE) is a public-private resource that integrates multiple clinical data streams from over 400 laboratory providers across the state in collaboration with California’s largest nonprofit health information exchange, fulfilling core aims of the Centers for Disease Control and Prevention’s Public Health Data Strategy (PHDS) while reinforcing a significant use case for the emerging health data utility (HDU) model.
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On March 4, 2020, Gavin Newsom, the Governor of California, proclaimed a state of emergency in response to the COVID-19 pandemic, which was followed by a federal Stafford Act emergency declaration for COVID-19 on March 22. As occurred elsewhere, the next weeks and months were characterized by a scramble across the state health system to marshal and deploy the resources necessary to diagnose and treat patients who had contracted the virus, while working to slow its spread. The inadequacy of CDPH’s existing system—the California Reportable Disease Information Exchange (CalREDIE)—for processing the massive increase in electronic lab reporting (ELR) volume from public and private lab facilities was recognized as a critical vulnerability during this period.[1] After a few early technical missteps, a new California COVID-19 reporting system (CCRS) “went live” in October 2020 before achieving full functionality in February 2021.[2]
At the same time, the acute phase of COVID-19 was accelerating a transformation in the basic structure and function of health information networks. The decade prior to the pandemic saw the largest investments in digital health infrastructure in American history, courtesy of the federal Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009. HITECH distributed billions of dollars annually in EHR adoption incentive payments for providers, and billions more in enhanced reimbursement and grants for public and nonprofit health information exchange (HIE) organizations in every state.[3] In California, statewide and regional HIE entities were limited before HITECH; by the time the last HITECH funding sunsetted and the state’s Data Exchange Framework (DxF) law was enacted in 2021, the six major HIEs designated by the state as DxF Qualified Health Information Organizations (QHIOs) were connected to nearly as many healthcare providers as CDPH itself, and working across multiple use cases apart from traditional point-to-point transmission of clinical data.
Central to this evolution is the increasing connectivity between the HIEs and public health agencies (PHAs) on the state and local level (including nearly 70% of California county health departments) and an array of community-based organizations (CBOs) addressing health-related social needs (HRSNs), creating integrated treatment and referral networks with common data elements under shared and collaborative governance.[4] The pandemic was an unprecedented test for these networks and an opportunity to demonstrate their reach, technical capabilities, and capacity for rapid innovation in the face of complex challenges. Among the activities enabled by HIE-led networks were the assimilation of COVID-19 contact tracing, labs, and treatment (and later vaccine status) data into millions of longitudinal patient records[5], while simultaneously feeding real-time information on provider resource allocation (inpatient bed capacity, staffing levels) to PHAs and hospitals[6]; building data dashboards to help track and predict cases at the community level; and helping clinicians manage post-COVID follow up for the most vulnerable patients via chronic care referrals and CBO service availability.[7] The tools, procedures, and (especially) institutional partnerships that emerged to meet these needs gave further credence to the model of health data organizations as nonprofit standalone entities broadly accountable to the public interest—emerging health data utilities (HDUs) at the center of public health[8] with implications for federal health information efforts.
In the year after CCRS launched, CDPH continued to maintain and expand it as the state’s repository for COVID-19 ELR, while CalREDIE remained the primary system for ELR and electronic case reporting (eCR) surveillance of more than 85 other diseases and conditions that providers report to their local public health departments.[9] Driven by the ongoing necessity of coronavirus coverage through waves of infection, diagnostic innovation, and the corresponding attention and resources, CCRS’ capabilities as a tool for the transmission and management of data at scale began to outstrip those of CalREDIE. By spring 2022, CDPH was seeking a way to better integrate the two systems and broaden CCRS’ digital jurisdiction to include other data streams and standards, which would leverage collaboration with a wider range of private and nonprofit stakeholders in the information ecosystem and improve the state surveillance enterprise as a whole. After a competitive bidding process, the three-year contract for this upgraded, more comprehensive network—called the Surveillance and Public Health Reporting and Exchange (SaPHIRE)—was awarded to Manifest MedEx (MX), the largest of California’s QHIOs by geography and population served, and one of its emerging HDUs.[10]
The structure of SaPHIRE, in which the system is designed, operated and managed by MX based on requirements from CDPH, represents another step forward in the transition from legacy HIEs to multi-functional HDUs in California (and given its sheer size, a notable case study nationally). Using the lessons learned from the first year of CCRS operations, CDPH’s objective was to extend the functionality of that system to ELR exchange and related applications for disease categories beyond COVID-19, and thus effectively merge elements of CCRS and CalREDIE while maintaining the latter as a standalone baseline service. SaPHIRE fulfills that goal as the “front door” for laboratories statewide to submit reports directly to CalREDIE, but much of its work is on the back-end of connectivity: aggregating, deduplicating, and standardizing data from multiple domains, streamlining intake from nearly 400 public and private labs across the state,[11] and populating dashboards for CDPH analysts and other public health stakeholders to dissect data in near real time. Among the greatest strengths of SaPHIRE is its modularity—its ability to add new applications with precision and relative speed—made possible by MX infrastructure.
As MX and CDPH continue to develop SaPHIRE’s capabilities, its success has also served in large measure as a proof-of-concept demonstration for their federal partners. The Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC) has highlighted the robust connections that HIEs nationwide have built with hospital labs in particular (89% of which provide test results to their service area HIEs)[12]as a model for improving commercial and public health lab interoperability, which the agency considers a priority in the context of its new information blocking regulations. At the same time, Centers for Disease Control and Prevention is pursuing a 2024-2025 Public Health Data Strategy (PHDS) which has elevated ELR as “the core of public health data” alongside eCR and direct data links between healthcare facilities and labs termed “electronic test orders and results” (ETOR).[13] The PHDS has accordingly set national goals of having 100% of the non-federal labs funded by the CDC’s Epidemiology and Laboratory Capacity (ELC) Program connected to state-based intermediaries for data exchange by the end of this year; 100% of those labs conducting ETOR transactions by the same deadline; 100% of them capable of receiving CDC infectious disease data from federal labs by the end of next year; and 65% receiving eCR reports for at least 75% of their state-reportable conditions by the end of next year. Thanks to SaPHIRE, California’s labs in question can claim all these benchmarks already—and do so as part of a comprehensive and technically consolidated HDU infrastructure that sets the standard for future progress.
References:
[1] “California undercounting COVID-19 cases due to ‘serious’ technical issues, counties say.” The Sacramento Bee. 4 August 2020. Available: https://www.sacbee.com/news/coronavirus/article244717192.html
[2] “Following test-results dust-up, California to unveil a new COIVD-19 reporting system in October.” The Los Angeles Times. 1 September 2020. Available: https://www.latimes.com/california/story/2020-09-01/california-new-covid-19-reporting-system-test-results
[3] Electronic Health Information Exchange. United States Government Accountability Office. April 2023. Available: https://www.gao.gov/assets/820/819458.pdf
[4] “HIE in California.” California Association of Health Information Exchanges. Available: https://cahie.org/initiatives/hie-in-ca/
[5] “LANES provides critical data sharing during COVID-19 public health crisis.” 24 April 2020. Available: https://lanesla.org/lanes-provides-critical-data-sharing-during-covid-19-public-health-crisis/
[6] “Adventist Sings Onto California HIE to Boost Patient Data Exchange.” TechTarget. 25 January 2021. Available: https://www.techtarget.com/searchhealthit/news/366579343/Adventist-Signs-Onto-California-HIE-to-Boost-Patient-Data-Exchange
[7] “Health Information Exchange in California: Assessment of Regional Market Activity.” California Health Care Foundation. August 2021. Available: https://www.chcf.org/wp-content/uploads/2021/02/HIECAAssessmentRegionalMarketActivity.pdf
[8] “Health Data Utility: From Vision to Reality in Many States.” Healthcare Innovation. 11 July 2023. Available: https://www.hcinnovationgroup.com/interoperability-hie/article/53063442/health-data-utility-from-vision-to-reality-in-many-states
[9] “Reportable Diseases and Conditions.” Division of Communicable Disease Control, California Department of Public Health. Available: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Reportable-Disease-and-Conditions.aspx
[10] “Five of the Nation’s Leading Health Data Organizations Launch Health Data Utility Maturity Model.” Manifest Medex. Available: https://www.manifestmedex.org/five-of-the-nations-leading-health-data-organizations-launch-health-data-utility-maturity-model/
[11] “Manifest MedEx awarded contract with the California Department of Public Health to implement new data system for the surveillance and public health information reporting and exchange (SaPHIRE).” Businesswire. 16 August 2022. https://www.businesswire.com/news/home/20220816005264/en/Manifest-MedEx-Awarded-Contract-with-the-California-Department-of-Public-Health-To-Implement-New-Data-System-for-the-Surveillance-and-Public-Health-Information-Reporting-and-Exchange-SaPHIRE
[12] ”Laboratory Interoperability for Health Information Exchange Organizations.” ASTP Data Brief No. 74. September 2024. Available: Laboratory Interoperability Through Health Information Exchange Organizations | HealthIT.gov
[13] “Public Health Data Strategy Milestones for 2024 and 2025.” Centers for Disease Control and Prevention. Available: https://www.cdc.gov/public-health-data-strategy/php/about/milestones-for-2024-and-2025.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fophdst%2Fpublic-health-data-strategy%2Fphds-milestones.html
