ORIGINAL ARTICLE An informatics framework for public health information systems: a case study on how an informatics structure for integrated information systems provides benefit in supporting a statewide response to a public health emergency Ivan J. Gotham • Linh H. Le • Debra L. Sottolano • Kathryn J. Schmit Received: 17 April 2013 / Revised: 8 October 2013 / Accepted: 23 January 2014 / Published online: 8 February 2014 � Springer-Verlag Berlin Heidelberg 2014 Abstract This chapter illustrates how a well-established public health informatics framework provides an integrated information system infrastructure that assures and enhances the efficacy of public health emergency preparedness (PHEP) actions throughout the phases of the health emergency event life cycle. Key PHEP activities involved in supporting this cycle include planning; surveillance; alerting; resource assessment and management; data-driven decision support; and intervention for prevention and control of disease or injury in populations. Information systems supporting these activities are most effective in assuring optimal response to an emergent health event when they are integrated within an informatics framework that supports routine (day to day) information exchange within the health infor- mation exchange community. In late April 2009, New York State (NYS) initiated a statewide PHEP response to the emergence of Novel Influenza A (H1N1), culmi- nating in a statewide vaccination campaign during the last quarter of 2009. The I. J. Gotham (&) School of Public Health, Department of Health Policy Management University at Albany, State University of New York , 1 University Place, Rensselaer, NY 12144, USA e-mail: [email protected] L. H. Le � K. J. Schmit New York State Department of Health, Office of Information Technology Service, Empire State Plaza, Room 148, Albany, NY 12237, USA e-mail: [email protected] K. J. Schmit e-mail: [email protected] L. H. Le Department of Nursing, Sage College, Albany, NY 12180, USA D. L. Sottolano Center for Health Care Quality & Surveillance, New York State Department of Health, 875 Central Avenue, Albany, NY 12206, USA e-mail: [email protected] 123 Inf Syst E-Bus Manage (2015) 13:713–749 DOI 10.1007/s10257-014-0240-9 http://crossmark.crossref.org/dialog/?doi=10.1007/s10257-014-0240-9&domain=pdf http://crossmark.crossref.org/dialog/?doi=10.1007/s10257-014-0240-9&domain=pdf established informatics framework of integrated information systems within NYS conveyed significant advantages and flexibility in supporting the range of PHEP activities required for an effective response to this health event. This chapter describes, and provides, performance metrics to illustrate how a public health informatics framework can enhance the efficacy of all phases of a public health emergency response. It also provides informatics lessons learned from the event. Keywords Public health informatics � Information systems � .

1. ORIGINAL ARTICLE
An informatics framework for public health
information systems: a case study
on how an informatics structure for integrated
information systems provides benefit in supporting
a statewide response to a public health emergency
Ivan J. Gotham • Linh H. Le • Debra L. Sottolano •
Kathryn J. Schmit
Received: 17 April 2013 / Revised: 8 October 2013 / Accepted:
23 January 2014 /
Published online: 8 February 2014
� Springer-Verlag Berlin Heidelberg 2014
Abstract This chapter illustrates how a well-established public
health informatics
framework provides an integrated information system
infrastructure that assures and
enhances the efficacy of public health emergency preparedness
(PHEP) actions
throughout the phases of the health emergency event life cycle.
Key PHEP activities
involved in supporting this cycle include planning; surveillance;
alerting; resource

2. assessment and management; data-driven decision support; and
intervention for
prevention and control of disease or injury in populations.
Information systems
supporting these activities are most effective in assuring
optimal response to an
emergent health event when they are integrated within an
informatics framework
that supports routine (day to day) information exchange within
the health infor-
mation exchange community. In late April 2009, New York
State (NYS) initiated a
statewide PHEP response to the emergence of Novel Influenza
A (H1N1), culmi-
nating in a statewide vaccination campaign during the last
quarter of 2009. The
I. J. Gotham (&)
School of Public Health, Department of Health Policy
Management University at Albany,
State University of New York , 1 University Place, Rensselaer,
NY 12144, USA
e-mail: [email protected]
L. H. Le � K. J. Schmit
New York State Department of Health, Office of Information
Technology Service,

3. Empire State Plaza, Room 148, Albany, NY 12237, USA
e-mail: [email protected]
K. J. Schmit
e-mail: [email protected]
L. H. Le
Department of Nursing, Sage College, Albany, NY 12180, USA
D. L. Sottolano
Center for Health Care Quality & Surveillance, New York State
Department of Health,
875 Central Avenue, Albany, NY 12206, USA
e-mail: [email protected]
123
Inf Syst E-Bus Manage (2015) 13:713–749
DOI 10.1007/s10257-014-0240-9
http://crossmark.crossref.org/dialog/?doi=10.1007/s10257-014-
0240-9&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s10257-014-
0240-9&domain=pdf
established informatics framework of integrated information
systems within NYS
conveyed significant advantages and flexibility in supporting
the range of PHEP

4. activities required for an effective response to this health event.
This chapter
describes, and provides, performance metrics to illustrate how a
public health
informatics framework can enhance the efficacy of all phases of
a public health
emergency response. It also provides informatics lessons
learned from the event.
Keywords Public health informatics � Information systems �
Public health emergency preparedness and response
1 Introduction
1.1 Public health informatics and information systems
While there are many definitions of ‘‘Information System’’ in
the literature, one
could distill the authors’ thoughts into the following
description:
An Information System is the arrangement of data, processes,
people, and
information technology that interact to collect, store and
communicate
information as needed to facilitate planning, control,
coordination and
decision making for a subject matter domain across an
enterprise. (See

5. Businessdictionary 2013; Whatis.techtarget 2013; Whitten and
Bentley 2007)
The practice of informatics is essential to assuring that
information systems are
successful and provide value (e.g. see Massoudi et al. 2012;
Chen et al. 2007). At
the most abstract level, Public Health Informatics (PHI) is
defined as ‘‘the
systematic application of information and computer science and
technology to
public health practice, research, and learning’’ (O’Carroll et al.
2003). The ultimate
goals of PHI, then, are to:
• assure development and governance of information systems
that can be
effectively used within the health enterprise to support routine
(day to day)
information exchange
• assure that those information systems provide value to both
Public Health
practitioners and their information trading partners (e.g. see
Massoudi et al.
2012).
PHI is therefore focused on implementing information systems

6. which support public
health activities that are integrated with, and supportive of, the
programmatic goals
of prevention and control of disease and injury in populations
(see Yasnoff et al.
2000; O’Carroll et al. 2003; Lombardo and Buckeridge 2007).
To be successful and
provide value, public health related information systems must
exist within an
operational informatics framework that embodies Health as an
enterprise and
supports the broader community of health information exchange
(e.g. see O’Carroll
et al. 2003; Kukafka and Yasnoff 2007; Gotham et al. 2010;
Massoudi et al. 2012).
Figure 1 depicts a paradigm for such a public health informatics
framework and,
as described below, public health emergency preparedness
(PHEP) provides an ideal
714 I. J. Gotham et al.
123
use case and means to evaluate its value proposition. The

7. framework, while
supported by technology, has as its focal point the health
information exchange
community sustained by value-added information trading
synergies (Fig. 1). This
information exchange community embodies the subject domains,
organizations and
jurisdictions of health as an enterprise. The synergy, or value
proposition, occurs
when information providers and recipients within that
community each derive
benefit through bi-directional ‘trading’, or exchange, of health
information. It is this
focus that drives the implementation of integrated information
systems governed by
the information needs, business rules, policies, regulations, and
data-sharing
agreements of the health enterprise.
Implementation of information systems is actualized by a
governance process
and based on measurable value and benefit as defined by the
enterprise (Fig. 1).
This process informs an agile informatics environment that is
able to respond

8. rapidly to both planned and emergent health information system
needs. This
environment is led by informaticians and health domain subject
matter experts and
supported by a team of technical experts, rapid development
tools, reusable services
and data (Fig. 1).
Within the context of a public health informatics framework,
these information
systems support public health activities such as disease
surveillance (see Chen et al.
2010; Lombardo and Buckeridge 2007) and outbreak
management, laboratory
reporting, health alerting, health care quality assurance, health
care resource
availability and capacity assessment, registry reporting and
situational awareness. A
model for assessing the value proposition of public health
information systems has
been developed by the Public Health Informatics Institute (PHII
2005). A detailed
business process and benefit analysis for interoperable
immunization registry data

9. exchange within a health information exchange community has
also been described
by Grannis, Dixon and Brand (2010). The Joint Public Health
Informatics Taskforce
has proposed a ‘‘consensus framework’’ to guide collaborations
across the public
health enterprise (JPHIT 2011).
The information systems within our model framework are in
turn supported by
enabling services (Fig. 1) that assure an arrangement and
interaction of data,
processes, people, and technology that effectively collects,
stores and communicates
heath information. These enabling services provide foundational
support for:
business rules and processes; effective use of information
systems; derivation of
information from data; reusable core functions and processes
that support multiple
information systems; as well as standardization and
interoperability of data and
information.
Services supporting business rules and processes would include
provision of user

10. account privileges and data access control management that
assures confidentiality
of data while at the same time providing seamless and
appropriate access to data
across information systems based on user role and need to
know. Services
underwriting effective use of information and underlying
systems include project
management, user training/support, common user interface and
single sign-on
across all information systems. Services supporting derivation
of information from
data include data analytics and visualization capabilities such as
GIS, dashboards,
integrated data reporting and query services, modeling and
statistical analysis
An informatics framework for public health information systems
715
123
packages. Services supporting standardization and
interoperability of data and
information include those standards that assure technical,

11. semantic and process
interoperability of health information exchange (see Benson
2012; IHE 2013).
Core functions and processes assure integration across
information systems and
sustainability through reuse of common services by those
systems. Examples
include:
• A common data layer service that assures all information
systems have the same
integrated view of health data and use the same authoritative
version of the
‘truth’.
• Common Directory services. These services include: a
communications
directory service that provides role and contact information for
organizations,
health providers and users; and a provider and health facility
directory service
which provides attribute information on health facilities (e.g.
geo-location,
staffed beds by specialty, isolation rooms, fixed equipment
assets) and providers
(e.g. certifications, practice status, populations served). Both
services provide a

12. common source of information to systems and users that is
consistent, reliable
and up to date.
• Common messaging, alerting and notification services that
allow the system and
its processes and users to transmit and confirm notifications to
organizations,
Fig. 1 Model Public Health Informatics Framework
716 I. J. Gotham et al.
123
users or other processes by multiple interoperable
communication venues (e.g.
voice, text, e-mail, XML).
• Common visualization and analysis services that allow users a
single interface to
information for a common operational picture of health
information or health
event status. The services allow information system processes to
automate
updating of those common operational pictures.
• A common permissions and access control interface provides
the authoritative

13. source for information systems to support workflow processes
and access rights
by user role.
The technical infrastructure layer of this framework assures that
information
systems and supportive enabling services are interoperable,
based on a Service
Oriented Architecture (SOA), secure, resilient and recoverable
from disasters,
highly available and able to accommodate surge in usage.
1.2 Benefit of an informatics framework and information
systems to public
health emergency preparedness
The US Federal Emergency Management Agency (FEMA 2011)
has established a
National Preparedness Goal (or NPG) for preventing and
responding to natural
disasters and terrorist attacks. The five components of the NPG
include: Prevention,
Protection, Mitigation, Response, and Recovery. These
components are cyclic in
nature, with lessons learned from response and recovery actions
from previous

14. emergency events feeding into improving the first three
components. The first three
components deal with actions to be taken in advance as
preparation for the potential
events through planning, drills/exercises, risk mitigation,
infrastructure develop-
ment and protection. In our discussion we will consolidate these
three components
into a single category: Preparedness.
Thus public health emergency preparedness (PHEP) is the
capability of public
health and healthcare systems, communities, and individuals to
prevent, protect
against, mitigate, quickly respond to, and recover from health
emergencies,
particularly those whose scale, timing, or unpredictability
threatens to overwhelm
routine capabilities. It is a state of sustainable ‘‘readiness to
act,’’ for all sectors and
stakeholders, that is achieved over time as part of the essential
public health
activities that health departments practice daily (see Gotham et
al. 2010).
This key point is an essential component of our model

15. informatics framework
(Fig. 1). PHEP activities/functions, if instantiated within such
an extensible or ‘dual
use’ framework, can be a value proposition of information
systems that are in daily
use for routine health information exchange by various health
organizations,
including Public Health. Indeed, as shown in preparedness drills
and exercises
(Gotham et al. 2007, 2010) and actual health events (Gotham et
al. 2001, 2007,
2008), the efficacy of information systems supporting PHEP is
optimized when
embedded within an established informatics framework
supporting a broad-based
community of health information trading partners engaged in
routine (day to day)
information exchange activities (Gotham et al. 2001, 2007,
2008, 2010).
An informatics framework for public health information systems
717
123

16. National Frameworks and Emergency Support Functions (ESF)
evolved as an
outcome of the NPG (see FEMA 2013). These define an
extensive list of core
capabilities and functions required to support the activities
involved in prepared-
ness, response and recovery. Among these are operational
coordination and
communication, threat and risk assessment, active and passive
surveillance,
detection, intelligence and information sharing, situational
awareness and decision
support, intervention campaigns, public information, resource
assessment for
response and recovery. These functions are singularly dependent
on bi-directional
exchange of information among response partners that is
authoritative, timely,
accurate, trusted, appropriate and up to date.
Effective information systems by our very definition are
absolutely critical in
assuring the efficacy of these activities and functions. Thus
effective public health
emergency preparedness requires rapid and agile leverage of

17. integrated information
systems that are readily adoptable in supporting novel emergent
situations as well as
core public health activities, such as planning and policy;
surveillance; alerting;
health resource assessment and management; situational
awareness, data-driven
decision support; and implementation, coordination and
management of public
health response and recovery interventions. Thus we can see
that our definition of
information system and our informatics framework are well
suited to encompassing
the needs of emergency preparedness.
In late April 2009, NY State (NYS) initiated a statewide PHEP
response to an
international health emergency: the emergence of Novel
Influenza A (H1N1). The
NYS response culminated in a statewide vaccination campaign
during last quarter of
2009. The established informatics framework of integrated
information systems
within NYS conveyed significant advantages and provided a
single point of input

18. and dissemination of critical information that supported the
range of PHEP activities
required for an effective response to this health event. This
chapter describes, and
provides, performance metrics that illustrate how a public
health informatics
framework and its information systems can enhance the efficacy
of all phases of a
Public Health emergency response. The chapter also provides
Informatics lessons
learned from the event.
2 A well established informatics framework and dual-use
information system
infrastructure plays an important role in preparedness for an
emergency
event
2.1 Established infrastructure needs to be in place prior to an
event
An element that is essential to the value proposition of our
informatics framework
paradigm (Fig. 1) is the ‘dual use’ nature of information
systems. That is, systems
that are familiar and in daily use by response partners for
routine health information

19. exchange are best suited for, and constitute a key aspect of the
‘‘preparedness’’
phases (prevent, protect, mitigate) that are necessary for
effective response and
recovery of an emergency event.
718 I. J. Gotham et al.
123
The NYSDOH informatics framework and its infrastructure have
evolved over
the past 17 years to support the state department of health’s
strategic approach to
information exchange within the community of its health
information trading
partners. The infrastructure, or Health Commerce System
(HCS), is a closed, web-
enabled portal, supporting secure information exchange
activities with all regulated
health entities in NY State (Gotham et al. 2001, 2007, 2008,
2010); see Table 1. The
flow of data and information within the HCS architecture and
its foundation
informatics framework (Fig. 1) are shown in Fig. 2

20. The information systems within the HCS support all health-
related, day-to-day
information exchange activities, from vital records and health
care quality assurance
and finance to disease registry and condition reporting,
statewide communicable
disease and laboratory reporting, arbovirus surveillance, child
health insurance
reporting, managed care, even prescription pad orders. Given
this mission, the HCS
architecture is multi-tiered, highly available, and with full off-
site disaster recovery
capabilities. That architecture, therefore, is a platform well
suited for responding to
public health emergencies, given its architecture and routine use
by partner
organizations who would be involved in the response. Thus,
based on our paradigm
(Fig. 1), an array of information systems has been implemented
within the HCS to
support both PHEP and routine core public health activities.
The PHEP functions and the HCS information systems used to
support them are

21. listed in Table 2 and their data flow within the HCS system is
shown in Fig. 2.
These systems support both routine and PHEP activities for
health alerting;
electronic laboratory and disease reporting; syndromic
surveillance; targeted health
facility patient surveillance; monitoring of health facility status
[e.g., Emergency
Department (ED) traffic]; health facility resource inventories
and antiviral inventory
tracking; general situational awareness; executive decision
support; school-based
surveillance and medical countermeasure administration (Table
2).
Of particular note is the Health Emergency Response Data
System, HERDS, an
information system that supports dynamic, real-time deployment
of ongoing
surveillance reporting and ad hoc surveys (see Gotham et al.
2007, 2010; Table 2).
HERDS is used for routine electronic reporting and surveys as
well as for
information exchange during emergency events. State, regional,
and local health

22. offices all have access to HERDS data as soon as it is reported
by health facilities.
Statewide data is typically available and integrated into
decision support systems
within 24 h of deployment of a HERDS survey (Table 2).
2.2 Routine, ongoing use of information systems leads to an
advance
preparedness advantage
The HCS PHEP information systems relevant to PHEP had been
in use for years
prior to the H1N1 Pandemic event and already had been used to
support statewide
responses to emergent infectious disease events, emergency
disaster declarations,
health resource shortages, elevated national threat levels and
high-profile national
security events (Gotham et al. 2001, 2007, 2008, 2010).
The HERDS system had been used to monitor statewide hospital
bed availability
and ED patient traffic reporting since June 2003, and provides
statewide, facility-
An informatics framework for public health information systems
719

23. 123
specific surveillance on bed availability by specialty type (e.g.,
adult and pediatric
medical/surgical, ICU, burn). The system has been used to
monitor ED patient
registrations, and had also been used to compile and maintain an
ongoing statewide
inventory of hospital assets since August 2004. The critical
asset survey, deployed
via HERDS, is an exhaustive inventory of current staffed and
surge capacity of beds
by specialty; special treatment capacities (e.g., trauma and burn
center, hyperbaric,
decontamination); transportation capacities; durable and fixed
equipment (e.g., adult
and pediatric ventilators, cardiac monitors); airborne infection
isolation room
capacity; staff capacities by specialty; communication and
generator capacities.
Reporting of laboratory-confirmed influenza cases, by age
group, among hospital
patients, has also been maintained on HERDS since December
2004. Along with

24. HCS dashboard analytics on the HCS (Table 2), HERDS was
instrumental in
supporting the NY State response to the national influenza
vaccine shortage in 2004
(Gotham et al. 2008).
Prior to the emergence of the H1N1 event, use of HERDS had
been expanded to
support routine surveillance and resource reporting by all Local
Health Departments
(LHDs), nursing homes, adult and home care entities, and
schools statewide.
Nursing home reporting of bed availability, critical assets, and
vaccination rates for
Table 1 NYS health commerce system (HCS) demographics and
usage as of July, 2009
Organization or user group Number Users
H1N1 vaccine providers 6,113 5,955
Clinical or environmental labs (Labs) 1,481 3,388
Clinics and treatment centers (Clinics) 1,498 7,369
Home and adult care facilities (adult care) 1,701 15,785
Hospitals 230

25. Local health departments (LHDs) 58 6,823
Medical professionals – 43,984
NYSDOH central health office 1 4,428
NYSDOH regional health offices 4 1,107
Nursing homes 663 12,287
School districts 1,311 4,259
Pharmacies 2,259 3,388
Other organizations 1,902 10,107
Usage statistics
250 applications
14,500 user logins per day
800,000 access hits per day
30 Gbytes in transactions per day
LHDs include NY City Department of Health and Mental
Hygiene
Other organizations include schools, fire and EMS, federal and
state agencies, tribal nations, managed
care organizations, etc. Organization counts are by physical
facility. Medical Professionals include MDs
and practices, dentists, veterinarians, physician assistants, nurse

26. practitioners
720 I. J. Gotham et al.
123
influenza and pneumococcal infection and other health care
surveillance is captured
in HERDS, as are reports, by all types of schools, of
vaccination rates and other
public health concerns. Given the established history of the
framework, information
systems and the technical infrastructure, the HCS infrastructure
had become an
integral component of NYS Health Department incident
management processes as
well as of NY State’s all-hazards and pandemic influenza plans
(see Gotham et al.
2007, 2010).
Emergency response plans and their underlying components
must be tested
periodically to assess their efficacy and revised according to
lessons learned. Thus
HCS and its information systems had been used as integral
functions in both routine

27. drills and full-scale exercises (Gotham et al. 2007). In spring of
2006, NY State
Department of Health (NYSDOH) conducted a full-scale
exercise simulating the
emergence of a novel influenza strain in the western region of
the state (Gotham
et al. 2010). The scenario was entirely data driven, lasted a
month in duration, and,
as part of NY’s pandemic influenza plan, leveraged its existing
informatics
infrastructure to support the ongoing ‘‘response.’’ The
information systems used by
the exercise participants to respond to the scenario included
health alerting,
epidemiological surveillance, health care resource and medical
countermeasure
management, and data-driven decision support through
integrated dashboard
visualization. Situational awareness was provided to all of the
organizational
Fig. 2 Health Commerce System (HCS) Technical Information
Architecture
An informatics framework for public health information systems
721

28. 123
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re
so
u
rc
e
a
n
d
a
ss
e
t

43. tr
a
c
k
in
g
,
su
rg
e
,
b
e
d
a
v
a
il
a
b
il
it
y
,
p
a
ti
e
n
t
tr
a
c
k
in

44. g
.
a
n
d
e
m
e
rg
e
n
c
y
re
sp
o
n
se
in
h
o
sp
it
a
ls
H
E
R
D
S
(s
c
h
o

45. o
l
in
st
a
n
c
e
)
D
y
n
a
m
ic
,
m
u
lt
it
a
sk
in
g
sy
st
e
m
su
p
p
o
rt
in

46. g
li
v
e
d
a
ta
fe
e
d
s
fo
r
st
a
te
-w
id
e
e
le
c
tr
o
n
ic
re
p
o
rt
in
g

47. o
f
d
a
ta
fr
o
m
b
o
th
p
u
b
li
c
a
n
d
p
ri
v
a
te
sc
h
o
o
ls
E
m

48. e
rg
e
n
c
y
D
e
p
a
rt
m
e
n
t
(E
D
)
S
u
rv
e
il
la
n
c
e
S
y
st
e
m
(E
D
S

49. U
R
V
)
A
u
to
m
a
te
d
re
p
o
rt
in
g
o
f
c
h
ie
f
c
o
m
p
la
in
t
d
a
ta
fo

50. r
e
m
e
rg
e
n
c
y
d
e
p
a
rt
m
e
n
t
a
d
m
is
si
o
n
s
fo
r
sy
n
d
ro
m
ic

51. su
rv
e
il
la
n
c
e
N
o
so
c
o
m
ia
l
O
u
tb
re
a
k
R
e
p
o
rt
in
g
A
p
p
li
c
a

52. ti
o
n
(N
O
R
A
)
R
e
p
o
rt
in
g
,
fo
ll
o
w
-u
p
a
n
d
c
lo
se
o
u
t
o
f
n
o

53. so
c
o
m
ia
ll
y
-a
c
q
u
ir
e
d
in
fe
c
ti
o
n
s
fo
r
in
d
iv
id
u
a
l
c
a
se
s
o

54. r
o
u
tb
re
a
k
s
o
f
c
o
m
m
u
n
ic
a
b
le
d
is
e
a
se
s
w
it
h
in
th
e
h

55. o
sp
it
a
l
a
n
d
n
u
rs
in
g
h
o
m
e
se
tt
in
g
s
D
is
e
a
se
re
p
o
rt
in
g
a

56. n
d
e
p
id
e
m
io
lo
g
ic
a
l
su
rv
e
il
la
n
c
e
R
e
p
o
rt
in
g
o
f
c
o
m
m

57. u
n
ic
a
b
le
d
is
e
a
se
c
a
se
s
c
o
m
m
u
n
ic
a
b
le
d
is
e
a
se
e

58. le
c
tr
o
n
ic
su
rv
e
il
la
n
c
e
sy
st
e
m
(C
D
E
S
S
)
S
ta
te
w
id
e
sy
st
e

59. m
fo
r
re
p
o
rt
in
g
o
f
d
is
e
a
se
c
a
se
s
fo
r
st
a
te
m
a
n
d
a
te
d
d

60. is
e
a
se
c
o
n
d
it
io
n
s
b
y
lo
c
a
l
h
e
a
lt
h
d
e
p
a
rt
m
e
n
ts
(L
H

61. D
)s
;
in
c
lu
d
e
s
c
o
n
ta
c
t
tr
a
c
in
g
a
n
d
in
te
g
ra
ti
o
n
w
it
h
E
le

62. c
tr
o
n
ic
L
a
b
o
ra
to
ry
R
e
p
o
rt
in
g
H
E
R
D
S
(c
o
u
n
ty
in
st
a

63. n
c
e
)
D
y
n
a
m
ic
,
m
u
lt
it
a
sk
in
g
sy
st
e
m
su
p
p
o
rt
in
g
li
v
e
d

64. a
ta
fe
e
d
s
fo
r
su
rv
e
il
la
n
c
e
a
n
d
su
rv
e
y
d
is
tr
ib
u
ti
o
n
a
n
d

65. re
tu
rn
fo
r
L
H
D
s
A
le
rt
in
g
a
n
d
C
o
m
m
u
n
ic
a
ti
o
n
P
ro
v
id
e

66. s
g
e
n
e
ra
l
a
n
d
ta
rg
e
te
d
h
e
a
lt
h
a
le
rt
in
g
a
n
d
n
o
ti
fi
c
a
ti

67. o
n
u
si
n
g
a
u
to
m
a
te
d
p
h
o
n
e
,
c
e
ll
,
fa
x
,
e
-m
a
il
a
n
d
se

68. c
u
re
w
e
b
p
o
st
in
g
s
C
o
m
m
u
n
ic
a
ti
o
n
s
D
ir
e
c
to
ry
(C
o
m

69. D
ir
)
C
e
n
tr
a
l
d
ir
e
c
to
ry
o
f
ro
le
a
n
d
c
o
n
ta
c
t
in
fo
rm
a

70. ti
o
n
fo
r
a
ll
H
C
S
p
a
rt
ic
ip
a
n
ts
;
m
a
in
ta
in
e
d
b
y
c
o
o
rd
in
a
to

71. rs
a
t
p
a
rt
ic
ip
a
n
t
H
C
S
o
rg
a
n
iz
a
ti
o
n
s
In
te
g
ra
te
d
h
e
a
lt

72. h
a
le
rt
in
g
a
n
d
n
o
ti
fi
c
a
ti
o
n
sy
st
e
m
(I
H
A
N
S
)
P
ro
v
id
e
s

73. h
e
a
lt
h
a
le
rt
in
g
a
n
d
n
o
ti
fi
c
a
ti
o
n
u
si
n
g
a
u
to
m
a
te
d
p
h
o

74. n
e
,
c
e
ll
,
fa
x
,
e
-m
a
il
,
a
n
d
w
e
b
p
o
st
in
g
s;
in
te
g
ra
te
d

75. w
it
h
C
o
m
D
ir
722 I. J. Gotham et al.
123
T
a
b
le
2
c
o
n
ti
n
u
e
d
G
e
n
e
ri
c

76. p
u
b
li
c
h
e
a
lt
h
e
m
e
rg
e
n
c
y
p
re
p
a
re
d
n
e
ss
fu
n
c
ti
o
n

77. A
c
ti
v
it
ie
s
su
p
p
o
rt
in
g
N
Y
S
P
H
E
P
p
re
p
a
re
d
n
e
ss
,
re
sp
o
n

78. se
a
n
d
re
c
o
v
e
ry
S
ta
te
w
id
e
in
fo
rm
a
ti
o
n
sy
st
e
m
o
n
H
C
S

79. su
p
p
o
rt
in
g
P
H
E
P
a
c
ti
v
it
ie
s
L
a
b
o
ra
to
ry
re
p
o
rt
in
g
E
le

80. c
tr
o
n
ic
re
p
o
rt
in
g
o
f
c
li
n
ic
a
l
te
st
re
su
lt
s
fr
o
m
c
li
n
ic
a

81. l,
p
u
b
li
c
a
n
d
n
a
ti
o
n
a
l
c
o
m
m
e
rc
ia
l
la
b
s
E
le
c
tr
o
n
ic

82. c
li
n
ic
a
l
la
b
o
ra
to
ry
re
p
o
rt
in
g
sy
st
e
m
(E
C
L
R
S
)
S
u
p
p
o

83. rt
s
a
u
to
m
a
te
d
a
n
d
m
a
n
u
a
l
e
le
c
tr
o
n
ic
re
p
o
rt
in
g
o
f
p
o

84. si
ti
v
e
te
st
re
su
lt
s
fo
r
re
p
o
rt
a
b
le
d
is
e
a
se
c
o
n
d
it
io
n
s
to

85. C
D
E
S
S
,
in
c
lu
d
in
g
in
fl
u
e
n
z
a
D
e
c
is
io
n
su
p
p
o
rt
,
d
a
ta

86. v
is
u
a
li
z
a
ti
o
n
a
n
d
si
tu
a
ti
o
n
a
l
a
w
a
re
n
e
ss
,
in
c
id
e
n

87. t
m
a
n
a
g
e
m
e
n
t
a
n
d
o
p
e
ra
ti
o
n
a
l
su
p
p
o
rt
P
ro
v
id
e

88. d
e
c
is
io
n
su
p
p
o
rt
,
si
tu
a
ti
o
n
a
l
a
w
a
re
n
e
ss
a
n
d
a
c
o
m
m

89. o
n
o
p
e
ra
ti
o
n
a
l
p
ic
tu
re
fo
r
e
x
e
c
u
ti
v
e
d
e
c
is
io
n
m
a
k

90. e
rs
a
t
lo
c
a
l,
re
g
io
n
a
l
a
n
d
st
a
te
le
v
e
ls
P
ro
v
id
e
ri
c
h
a

91. n
d
in
te
ra
c
ti
v
e
v
is
u
a
li
z
a
ti
o
n
o
f
e
v
e
n
t-
re
la
te
d
d
a
ta
fr

92. o
m
a
c
ro
ss
d
a
ta
so
u
rc
e
s
to
a
ll
p
ro
g
ra
m
s
a
n
d
o
rg
a
n
iz
a

93. ti
o
n
s
in
v
o
lv
e
d
in
th
e
re
sp
o
n
se
e
ff
o
rt
P
ro
v
id
e
g
e
n
e
ra

94. l
si
tu
a
ti
o
n
a
l
a
w
a
re
n
e
ss
to
th
e
c
o
m
m
u
n
it
y
o
f
H
C
S
o
rg

95. a
n
iz
a
ti
o
n
s
E
x
e
c
u
ti
v
e
d
a
sh
b
o
a
rd
a
n
d
d
a
ta
v
is
u
a

96. li
ze
r
A
c
c
e
ss
-c
o
n
tr
o
ll
e
d
sy
st
e
m
p
ro
v
id
in
g
h
ig
h
-l
e
v
e
l

97. si
tu
a
ti
o
n
a
l
a
w
a
re
n
e
ss
to
k
e
y
d
e
c
is
io
n
m
a
k
e
r
ro
le
s
a

98. c
ro
ss
re
sp
o
n
se
p
a
rt
n
e
r
o
rg
a
n
iz
a
ti
o
n
s;
in
te
g
ra
te
s
a
n
d

99. su
m
m
a
ri
z
e
s
m
u
lt
ip
le
d
a
ta
st
re
a
m
s
(H
E
R
D
S
,
C
D
E
S
S
)

100. in
to
g
ra
p
h
ic
a
l
d
is
p
la
y
s
E
v
e
n
t-
sp
e
c
ifi
c
w
e
b
si
te
A
w

101. e
b
si
te
w
it
h
in
th
e
H
C
S
p
ro
v
id
in
g
in
fo
rm
a
ti
o
n
p
o
st
in
g
s
a

102. n
d
u
p
d
a
te
s
to
e
n
ti
re
H
C
S
c
o
m
m
u
n
it
y
d
u
ri
n
g
a
n
e
v
e

103. n
t
S
e
c
u
re
fi
le
v
ie
w
e
r
S
u
p
p
o
rt
s
se
c
u
re
‘p
u
sh
’
o
f

104. st
a
ti
c
c
o
n
te
n
t
to
ta
rg
e
te
d
ro
le
s
a
n
d
o
rg
a
n
iz
a
ti
o
n
s
V
ir

105. tu
a
l
H
e
a
lt
h
O
p
e
ra
ti
o
n
s
C
e
n
te
r
(V
H
O
C
)
A
c
c
e
ss
-c
o
n
tr

106. o
ll
e
d
sy
st
e
m
u
se
d
to
su
p
p
o
rt
p
la
n
n
in
g
,
in
c
id
e
n
t
m
a
n
a

107. g
e
m
e
n
t
p
ro
c
e
ss
a
n
d
d
is
c
u
ss
io
n
fo
ru
m
s
b
e
tw
e
e
n
o
rg
a

108. n
iz
a
ti
o
n
s
a
n
d
in
c
id
e
n
t
c
o
m
m
a
n
d
in
v
o
lv
e
d
in
th
e
e
v

109. e
n
t
M
e
d
ic
a
l
c
o
u
n
te
r
m
e
a
su
re
re
sp
o
n
se
a
d
m
in
is
tr
a
ti

110. o
n
a
n
d
in
v
e
n
to
ry
R
e
p
o
rt
in
g
a
n
d
m
a
n
a
g
e
m
e
n
t
o
f
p
a

111. ti
e
n
t
d
a
ta
a
n
d
m
e
d
ic
a
l
c
o
u
n
te
r
m
e
a
su
re
s
a
n
d
in
fl
u

112. e
n
z
a
v
a
c
c
in
a
ti
o
n
s
C
li
n
ic
d
a
ta
m
a
n
a
g
e
m
e
n
t
sy

113. st
e
m
(C
D
M
S
)
D
y
n
a
m
ic
,
fo
rm
s-
b
a
se
d
sy
st
e
m
fo
r
re
p
o
rt

114. in
g
a
n
d
m
a
n
a
g
e
m
e
n
t
o
f
a
n
y
m
e
d
ic
a
l
c
o
u
n
te
rm
e
a

115. su
re
o
r
p
ro
p
h
y
la
c
ti
c
a
d
m
in
is
te
re
d
fr
o
m
c
o
u
n
ty
c
li
n
ic

116. s
o
r
P
o
in
ts
o
f
D
is
tr
ib
u
ti
o
n
(P
O
D
s)
.
A
ls
o
u
se
d
in
a
n
n
u
a

117. l
L
H
D
-b
a
se
d
se
a
so
n
a
l
in
fl
u
e
n
z
a
c
li
n
ic
s
N
Y
S
ta
te
Im
m

118. u
n
iz
a
ti
o
n
in
fo
rm
a
ti
o
n
sy
st
e
m
(N
Y
S
II
S
)
Im
m
u
n
iz
a
ti
o
n

119. re
g
is
tr
y
,
su
p
p
o
rt
in
g
m
a
n
d
a
te
d
re
p
o
rt
in
g
o
f
v
a
c
c
in
a
ti
o

120. n
s
b
y
m
e
d
ic
a
l
p
ro
fe
ss
io
n
a
ls
to
c
h
il
d
re
n
a
g
e
s
u
n
d
e
r

121. 1
9
)
An informatics framework for public health information systems
723
123
entities that might directly participate in the response or
contribute resources to
facilitate the response. Exercise participants included multiple
state agencies, state
and local health departments, and health care facilities.
The exercise provided the opportunity to measure the response
rates and
utilization metrics for the information systems supporting PHEP
activities. It
demonstrated that the presence of an established, integrated
informatics framework
for health information exchange conveys significant advantages
in advancing
preparedness in terms of rapid and accurate execution of
requested actions and
responses within a simulated emergency event (Gotham et al.
2010). Lessons

122. learned from the exercise were used to improve the information
system’s
capabilities for response to emergent events. The exercises and
drills were of
fortuitous benefit: in early spring 2009, nearly 3 years to the
day of the 2006
exercise, NYS activated its Incident Management System (IMS)
in response to the
emergence of Novel Influenza A (H1N1) within the state. All of
the HCS PHEP-
related information systems and informatics infrastructure was
called upon to
respond to the event.
3 Background and history of events surrounding NY state
response to a public
health emergency: Novel Influenza A (H1N1)
In mid-March, 2009, the Mexican government identified 3
separate events of
increased influenza-like illness (ILI) and pneumonia along with
rising death tolls
that caused it to close schools, cancel public events, and isolate
ill individuals at
places of work (WHO 2009). On April 24, 2009, NYSDOH
activated its Incident

123. Management System (IMS) in collaboration with NY City
Department of Health
and Mental Hygiene as a preparatory measure in anticipation of
positive test results
for what was then called Swine Origin Influenza A (H1N1)
among a cluster of
respiratory illnesses within a student cohort at a NY City school
(US CDC 2009a).
On Saturday, April 25, NYSDOH initiated a health alerting
process, providing
initial guidance to local health and health care entities in NY.
By April 26 several of
the NY City specimens had tested positive (US CDC 2009a) and
by April 28, 2009,
there were 45 confirmed cases in NY (US CDC 2009b),
NYSDOH IMS was in full
response mode, and all PHEP information systems were actively
engaged in
supporting the response.
The rapidly advancing geographic spread of the Novel Influenza
strain led the US
Government to declare the situation a public health emergency
on April 26 (US

124. CDC 2010a). On June 11, the World Health Organization
(WHO) raised the
pandemic alert level to Phase 6, signaling that a global
pandemic was under way
(US CDC 2010a). As of June 11, NYSDOH’s website reported
over a thousand
confirmed cases of H1N1 distributed across 40 NY counties and
NY City. By late
June 2009, the disease was becoming better understood (CDC
2009c, 2010a) and
early estimates by the CDC put the total US cases at between
1.8 and 5.7 million by
late July (Reed et al. 2009). Atypically, the H1N1 influenza
activity peaked in late
spring, decreased in midsummer, and increased again in fourth
quarter 2009 (see
CDC 2010b). The picture was complicated by the fact that (the
usual) ‘‘seasonal’’
724 I. J. Gotham et al.
123
influenza activity remained high throughout the summer and
displayed the same

125. multimodal pattern of activity (see CDC 2010b). The experience
reinforced the
importance of information systems and procedures for timely
communication, data
collection and analysis to support science-based public health
decisions in
responding to this event.
Absent a vaccine for H1N1 when the national public health
emergency was
declared, the Centers for Disease Control (CDC) Strategic
National Stockpile (SNS)
program began releasing inventories of antiviral medications
and respiratory and
personal protective equipment to the States, including NY (US
CDC 2010a). These
assets, in combination with NY State’s medical reserve cache,
were forward-
deployed to supplement potential shortages in medications and
infection control. In
June 2009, plans were under way to implement a national H1N1
vaccination
campaign to control the anticipated re-emergence of the disease
in fall of 2009 (see
CDC 2010a). The expected availability date of the H1N1

126. vaccine was October 2009.
Given the short time frame and competition for resources
needed for the seasonal
flu vaccine, however, it was anticipated that the supplies would
be limited. In late
July 2009, the CDC’s Advisory Committee on Immunization
Practices (ACIP)
released guidance on H1N1 vaccination administration based on
the disease
characteristics, concern over the potential for increased severity
upon re-emergence,
and limited availability of vaccine at the start. The guidance
assigned priority to
specific groups of individuals to receive the vaccine, including
health care workers
(see CDC 2010a). As in the 2004 vaccine shortage (Gotham et
al. 2008), States were
given local autonomy to sub-allocate CDC allocations. States
would identify
vaccination providers by priority group, determine the provider
sub-allocation, and
electronically place orders for specific products with the CDC;
the CDC would ship
the product to the designated provider through an independent

127. agent.
4 PHEP activities and information systems supporting response
to the event
The general pattern of PHEP activities and information system
use during the
response phase of the event lifecycle related to the emergence
of H1N1 was similar
to that which occurred during the emergence of West Nile Virus
in NY State in
1999 (see Gotham et al. 2001). The overall PHEP response to
the novel influenza
event occurred in three phases spread out over a period of 9
months. In analogy with
a foot race: Phase 1 was a sprint, immediately followed by a
long distance marathon
(Phases 2 and 3).
The initial response phase occurred from late April through
mid-June 2009.
During that time, NY State had to rely on the Pandemic flu
plan, HCS information
systems and informatics infrastructure that existed at the time.
In the second phase
(June to mid-September 2009), more was known about the
disease, its activity

128. ebbed and Federal vaccine response plans were in process.
In Phase 2 (June to mid-September 2009), PHEP activities
involved continued
monitoring and surveillance of disease activity for any changes
in status in the
community and health care settings. This phase also involved
intensive planning
and information system development/modification activities to
prepare for the re-
An informatics framework for public health information systems
725
123
emergence of the disease in fall 2009 and for a statewide
vaccination campaign to
start in October when that countermeasure would become
available. The planning
and information system development activities were based on
lessons learned from
Phase 1, NY State health executive governance policies and
needs (Fig. 1) and
federal vaccine response plans and policies.

129. The third phase involved implementation of the response plan,
which included
the H1N1 vaccine campaign as a public health intervention to
control the spread of
the disease (September 2009 to January 2010). Table 3 lists the
public health
activities, the HCS information systems supporting them, and
how they were used
throughout the phases of response.
4.1 Phase 1: established information systems supported the
initial response
to the emergency health event
The initial response required intensive health alerting and
communication of
situational awareness to, and among, response partners in the
health community;
rapid gathering and distribution of data related to surveillance
and assessment of
disease severity, geographic spread, and antiviral resistance;
assessment of the
impact on health care resources; control and mitigation of
infection in the health
care and community settings; management and distribution of
antiviral counter-

130. measures and respiratory and personal protective equipment.
There was an immediate imperative for situational awareness
and guidance from
a single authoritative source that could provide rapid
distribution of guidance,
advisories and updates and related communiqués statewide to
the global HCS
community (Figs. 1, 2; Table 1), including all Local Health
Departments (LHDs),
acute care and long-term care facilities, clinical laboratories,
and health providers.
The Integrated Health Alerting and Notification System
(IHANS) and event-specific
website within the HCS system provided the methodology for
distribution of these
materials (Table 3) and the HCS health information exchange
community provided
the venue (Figs. 1, 2; Table 1).
Access to event-specific information was also important:
laboratory and case
reporting of suspect and confirmed cases were supported by
existing HCS systems
(Tables 2, 3, see ECLRS and CDESS). Syndromic Surveillance

131. was maintained
through the HCS Emergency Department Surveillance System
(Tables 2, 3, see
EDSURV). Healthcare-based outbreaks were monitored via the
Nosocomial
Outbreak Reporting Applications (see NORA, Tables 2, 3). The
HERDS system
(Tables 2, 3) was leveraged to provide heightened surveillance
on increases in
patients presenting with febrile or Influenza-Like Illness (ILI)
at hospitals;
assessment of impact on health care status (e.g., ED traffic);
assessment of critical
healthcare resource inventories (e.g., Personal Protective
Equipment and antiviral
medications); tracking of antiviral medications distributed to
the state through the
Strategic National Stockpile (SNS); and assessment of vendor-
managed inventories
of antiviral medications available through pharmacy chains.
Additional baseline information was also required, including
seasonal influenza
surveillance data from acute health care facilities; inventories
of fixed health care

132. assets from acute and long-term care facilities (e.g., ventilators,
airborne isolation
726 I. J. Gotham et al.
123
infection rooms); and bed availability. As the demographics of
the viral infections
became better understood, guidances regarding school closings
and absenteeism
were distributed via the health alert system and event website
(Table 3). School
absenteeism surveillance, required to make decisions regarding
school closings, was
implemented through the HERDS system (Table 3), allowing all
schools across NY
State to report this data and receive event information in
exchange. The dynamic
nature of the HERDS information system allowed for real time
creation of reports
for each of these needs, with information provided on
appropriate levels to the
decision makers across the HCS domain of response partners
(see Tables 2, 3;

133. Gotham et al. 2007)
Situational awareness and decision support were paramount for
the executive
policy and decision makers across the domains of the health
information enterprise
of the HCS community. Data feeds from surveillance, health
care resource
monitoring, and health care facility status were integrated into
the HCS executive
dashboard and data visualization system as well as a Virtual
Health Operations
Center (Tables 2, 3) to provide situational awareness and
decision support for
executives within the Incident Management System (IMS)
(Table 3, see also
Gotham et al. 2010).
Thus the existing HCS information systems supported the
response to the initial
phase of the emergency response. However, the marathon phase
of the response was
about to begin.
5 Phase 2: an established informatics framework enabled agile
development

134. of new or modified information systems to support recovery,
planning
and preparedness for disease re-emergence and countermeasure
intervention
The second phase of the H1N1 event encompasses both the
‘‘recovery’’ phase of the
event lifecyle, that is, recovery from Phase 1 and re-initiation of
the cycle into
‘‘preparedness’’ for what, at the time, was envisioned as Phase
3: re-emergence of
the disease and medical countermeasures against it. One
component of Phase 2
involved ongoing monitoring and surveillance of disease
activity for any changes in
status in the community and health care settings as well as
alerting and situational
awareness reporting. These activities were supported by the
existing HCS
information systems (Tables 2, 3). A second component of
Phase 2 involved
engaging in intensive planning activities to prepare for the re-
emergence of the
disease and a vaccine countermeasure campaign in fall 2009.
Federal policies, distribution plans, reporting mandates, as well
as lessons

135. learned locally from Phase 1 by NY State dictated that
completely new intervention
and surveillance plans had to be developed to support a
federally-brokered, state
fiduciary-based vaccination campaign. The campaign was slated
to start that
October when federal entities would make the vaccine available
to providers and
states. The existing PHEP systems, such as HERDS, were well
tuned to the
information needs of an emergent event of short duration. The
existing Immuni-
zation Registry and clinic data management system were well
suited to monitoring
administration of vaccines by providers and mass vaccination
clinics (Tables 2, 3).
An informatics framework for public health information systems
727
123
T
a
b
le

136. 3
P
u
b
li
c
h
e
a
lt
h
e
m
e
rg
e
n
c
y
p
re
p
a
re
d
n
e
ss
(P
H
E
P
)
a

137. c
ti
v
it
ie
s
a
n
d
N
Y
S
ta
te
h
e
a
lt
h
c
o
m
m
e
rc
e
sy
st
e
m
(H
C
S
)

138. in
fo
rm
a
ti
o
n
sy
st
e
m
s
su
p
p
o
rt
in
g
th
e
e
m
e
rg
e
n
c
y
re
sp
o
n
se

139. to
H
1
N
1
P
H
E
P
fu
n
c
ti
o
n
a
n
d
d
a
ta
/i
n
fo
rm
a
ti
o
n
so
u
rc
e

140. s
A
c
ti
v
it
ie
s
su
p
p
o
rt
in
g
P
H
E
P
re
sp
o
n
se
H
C
S
in
fo
rm
a
ti
o

141. n
sy
st
e
m
P
la
n
n
in
g
a
n
d
in
c
id
e
n
t
m
a
n
a
g
e
m
e
n
t
S
ta
te
,

142. re
g
io
n
a
l
a
n
d
lo
c
a
l
h
e
a
lt
h
o
ffi
c
ia
ls
S
u
p
p
o
rt
e
le
c
tr
o

143. n
ic
c
o
ll
a
b
o
ra
ti
o
n
fo
r
d
e
v
e
lo
p
m
e
n
t,
d
is
tr
ib
u
ti
o
n
a
n

144. d
c
o
m
m
e
n
t
o
n
re
sp
o
n
se
p
la
n
s
a
s
th
e
y
e
v
o
lv
e
d
b
e
tw
e

145. e
n
Ju
n
e
a
n
d
A
u
g
u
st
2
0
0
9
S
u
p
p
o
rt
th
e
N
Y
S
H
e
a
lt
h
In
c

146. id
e
n
t
C
o
m
m
a
n
d
S
y
st
e
m
(I
C
S
),
th
ro
u
g
h
e
le
c
tr
o
n
ic
c
o

147. ll
a
b
o
ra
ti
o
n
,
m
is
si
o
n
a
ss
ig
n
m
e
n
ts
a
n
d
si
tu
a
ti
o
n
re
p
o

148. rt
s
V
ir
tu
a
l
h
e
a
lt
h
o
p
e
ra
ti
o
n
s
c
e
n
te
r
(V
H
O
C
)
E
p
id

149. e
m
io
lo
g
ic
su
rv
e
il
la
n
c
e
H
o
sp
it
a
ls
st
a
te
w
id
e
M
o
n
it
o
r

150. h
o
sp
it
a
l
a
d
m
is
si
o
n
s/
d
e
a
th
s
w
it
h
la
b
o
ra
to
ry
c
o
n
fi
rm
e

151. d
se
a
so
n
a
l
in
fl
u
e
n
z
a
b
y
a
g
e
g
ro
u
p
M
o
n
it
o
r
h
o
sp
it
a
l

152. a
d
m
is
si
o
n
s/
d
e
a
th
s
d
u
e
to
a
c
u
te
fe
b
ri
le
re
sp
ir
a
to
ry
il

153. ln
e
ss
b
y
a
g
e
M
o
n
it
o
r
In
fl
u
e
n
z
a
-l
ik
e
il
ln
e
ss
(I
L
I)
sy
m

154. p
to
m
s
fo
r
e
m
e
rg
e
n
c
y
d
e
p
a
rt
m
e
n
t
(E
D
)
a
d
m
is
si
o
n
s
(N

155. Y
C
it
y
)
H
E
R
D
S
—
h
o
sp
it
a
l
in
st
a
n
c
e
C
o
n
d
u
c
t
E
D

156. sy
n
d
ro
m
ic
su
rv
e
il
la
n
c
e
b
a
se
d
o
n
c
h
ie
f
c
o
m
p
la
in
t
d
a

157. ta
o
n
E
D
a
d
m
is
si
o
n
E
m
e
rg
e
n
c
y
d
e
p
a
rt
m
e
n
t
su
rv
e
il

158. la
n
c
e
(E
D
S
U
R
V
)
S
c
h
o
o
ls
a
n
d
sc
h
o
o
l
d
is
tr
ic
ts
st
a
te

159. w
id
e
C
o
ll
e
c
t
st
u
d
e
n
t
a
n
d
fa
c
u
lt
y
a
b
se
n
te
e
is
m
fr
o
m

160. sc
h
o
o
ls
a
n
d
sc
h
o
o
l
d
is
tr
ic
ts
in
su
p
p
o
rt
o
f
n
o
v
e
l
a
n

161. d
se
a
so
n
a
l
in
fl
u
e
n
z
a
su
rv
e
il
la
n
c
e
H
E
R
D
S
—
sc
h
o
o
l

162. in
st
a
n
c
e
L
o
c
a
l
H
e
a
lt
h
d
e
p
a
rt
m
e
n
ts
(L
H
D
s)
st
a
te
w

163. id
e
S
ta
te
w
id
e
e
le
c
tr
o
n
ic
c
o
m
m
u
n
ic
a
b
le
d
is
e
a
se
c
a

164. se
re
p
o
rt
in
g
b
y
L
H
D
s—
n
o
v
e
l
in
fl
u
e
n
z
a
c
a
se
re
p
o
rt
in

165. g
fr
o
m
se
n
ti
n
e
l
fa
c
il
it
ie
s
C
o
m
m
u
n
ic
a
b
le
d
is
e
a
se

166. e
le
c
tr
o
n
ic
su
rv
e
il
la
n
c
e
sy
st
e
m
(C
D
E
S
S
)
C
li
n
ic
a
l
la
b

167. o
ra
to
ri
e
s
(N
a
ti
o
n
a
l,
P
ri
v
a
te
in
S
ta
te
a
n
d
H
o
sp
it
a
l)

168. A
u
to
m
a
te
d
re
p
o
rt
in
g
o
f
p
o
si
ti
v
e
te
st
re
su
lt
s
fo
r
re
-
p
o
rt

169. a
b
le
d
is
e
a
se
c
o
n
d
it
io
n
s,
in
te
g
ra
te
d
w
it
h
C
D
E
S
S
—
P
o
si

170. ti
v
e
In
fl
u
e
n
z
a
te
st
re
su
lt
s
b
y
ty
p
e
,
in
c
lu
d
in
g
n
o
v
e
l
in
fl

171. u
e
n
z
a
E
le
c
tr
o
n
ic
c
li
n
ic
a
l
la
b
o
ra
to
ry
re
p
o
rt
in
g
sy
st
e

172. m
(E
C
L
R
S
)
728 I. J. Gotham et al.
123
T
a
b
le
3
c
o
n
ti
n
u
e
d
P
H
E
P
fu
n

173. c
ti
o
n
a
n
d
d
a
ta
/i
n
fo
rm
a
ti
o
n
so
u
rc
e
s
A
c
ti
v
it
ie
s
su
p
p

174. o
rt
in
g
P
H
E
P
re
sp
o
n
se
H
C
S
in
fo
rm
a
ti
o
n
sy
st
e
m
N
u
rs
in
g
h

175. o
m
e
s
a
n
d
h
o
sp
it
a
ls
R
e
p
o
rt
in
g
o
f
n
o
so
c
o
m
ia
ll
y
a
c
q
u

176. ir
e
d
in
fe
c
ti
o
n
s;
a
re
a
s
o
f
th
e
fa
c
il
it
y
in
v
o
lv
e
d
,
n
u
m
b
e

177. r
a
n
d
d
is
p
o
si
ti
o
n
o
f
a
ff
e
c
te
d
p
a
ti
e
n
ts
,
a
n
d
in
fe
c
ti
o

178. n
c
o
n
tr
o
l
m
e
a
su
re
s
ta
k
e
n
to
c
o
n
ta
in
a
n
d
m
a
n
a
g
e
th
e

179. o
u
tb
re
a
k
N
o
so
c
o
m
ia
l
o
u
tb
re
a
k
re
p
o
rt
in
g
a
p
p
li
c
a
ti
o
n

180. s
(N
O
R
A
)
M
o
n
it
o
r
a
n
d
tr
a
c
k
h
e
a
lt
h
c
a
re
fa
c
il
it
y
st

181. a
tu
s,
re
so
u
rc
e
u
ti
li
za
ti
o
n
a
n
d
a
v
a
il
a
b
il
it
y
,
su
rg
e
c
a
p
a
c

182. it
y
H
o
sp
it
a
ls
In
v
e
n
to
ry
st
a
te
w
id
e
h
o
sp
it
a
l
a
ss
e
ts
a
n

183. d
e
q
u
ip
m
e
n
t
d
e
e
m
e
d
e
ss
e
n
ti
a
l
to
e
m
e
rg
e
n
c
y
re
sp
o

184. n
se
(e
.g
.
p
h
a
rm
a
c
y
in
v
e
n
to
ry
,
d
ia
g
n
o
st
ic
e
q
u
ip
m
e

185. n
t,
li
fe
su
p
p
o
rt
e
q
u
ip
m
e
n
t,
su
p
p
li
e
s,
p
e
rs
o
n
a
l
p
ro
te
c
ti

186. v
e
e
q
u
ip
m
e
n
t
(P
P
E
),
a
ir
b
o
rn
e
in
fe
c
ti
o
n
is
o
la
ti
o
n
ro
o
m

187. s
(A
II
R
))
M
o
n
it
o
r
h
o
sp
it
a
l
b
e
d
a
v
a
il
a
b
il
it
y
b
y
st
a
ff

188. e
d
se
rv
ic
e
(e
.g
.
a
d
u
lt
/p
e
d
ia
tr
ic
:
m
e
d
ic
a
l
su
rg
ic
a
l,
E
D
,
In

189. te
n
si
v
e
C
a
re
U
n
it
(I
C
U
))
M
o
n
it
o
r
e
v
e
n
t-
re
la
te
d
h
o
sp
it

190. a
l
re
so
u
rc
e
u
ti
li
z
a
ti
o
n
(e
.g
.
v
e
n
ti
la
to
rs
)
a
n
d
fa
c
il
it
y
st

191. re
ss
st
a
tu
s
(f
a
c
il
it
y
e
m
e
rg
e
n
c
y
p
la
n
a
c
ti
v
a
te
d
,
d
iv
e

192. rs
io
n
st
a
tu
s,
su
rg
e
st
ra
te
g
ie
s
a
c
ti
v
a
te
d
)
H
E
R
D
S
—
h
o
sp

193. it
a
l
in
st
a
n
c
e
L
o
n
g
te
rm
c
a
re
fa
c
il
it
ie
s
In
v
e
n
to
ry
st

194. a
te
w
id
e
n
u
rs
in
g
h
o
m
e
a
ss
e
ts
a
n
d
e
q
u
ip
m
e
n
t
d
e
e
m
e
d

195. e
ss
e
n
ti
a
l
to
e
m
e
rg
e
n
c
y
re
sp
o
n
se
(e
.g
.
p
h
a
rm
a
c
y
in

196. v
e
n
to
ry
,
d
ia
g
n
o
st
ic
e
q
u
ip
m
e
n
t,
li
fe
su
p
p
o
rt
e
q
u
ip
m
e

197. n
t,
su
p
p
li
e
s,
P
P
E
)
M
o
n
it
o
r
n
u
rs
in
g
h
o
m
e
b
e
d
a
v
a
il
a

198. b
il
it
y
b
y
st
a
ff
e
d
se
rv
ic
e
H
E
R
D
S
—
n
u
rs
in
g
h
o
m
e
in
st
a

199. n
c
e
A
le
rt
in
g
a
n
d
C
o
m
m
u
n
ic
a
ti
o
n
An informatics framework for public health information systems
729
123
T
a
b
le

200. 3
c
o
n
ti
n
u
e
d
P
H
E
P
fu
n
c
ti
o
n
a
n
d
d
a
ta
/i
n
fo
rm
a
ti
o
n

201. so
u
rc
e
s
A
c
ti
v
it
ie
s
su
p
p
o
rt
in
g
P
H
E
P
re
sp
o
n
se
H
C
S
in
fo
rm

202. a
ti
o
n
sy
st
e
m
G
lo
b
a
l
H
C
S
c
o
m
m
u
n
it
y
(s
e
e
T
a
b
le
1

203. )
D
is
tr
ib
u
te
g
e
n
e
ra
l
n
o
ti
fi
c
a
ti
o
n
s
a
n
d
a
le
rt
s
re
g
a
rd

204. in
g
n
o
v
e
l
in
fl
u
e
n
z
a
d
is
e
a
se
st
a
tu
s,
v
a
c
c
in
e
a
v
a
il
a

205. b
il
it
y
,
in
fe
c
ti
o
n
c
o
n
tr
o
l,
st
a
te
a
n
d
fe
d
e
ra
l
g
u
id
a
n
c

206. e
to
H
C
S
c
o
m
m
u
n
it
y
In
te
g
ra
te
d
h
e
a
lt
h
a
le
rt
in
g
a
n
d
n

207. o
ti
fi
c
a
ti
o
n
sy
st
e
m
(I
H
A
N
S
)
a
n
d
c
o
m
m
u
n
ic
a
ti
o
n
s
d

208. ir
e
c
to
ry
(C
o
m
D
ir
)
T
a
rg
e
te
d
h
e
a
lt
h
re
sp
o
n
se
p
a
rt
n
e
rs

209. (L
H
D
s,
h
o
sp
it
a
ls
,
lo
n
g
te
rm
c
a
re
fa
c
il
it
ie
s,
m
e
d
ic
a
l
p
ro

210. fe
ss
io
n
a
ls
)
C
u
st
o
m
iz
e
d
o
rg
a
n
iz
a
ti
o
n
—
a
n
d
ro
le
-s
p
e
c
ifi

211. c
d
is
tr
ib
u
ti
o
n
o
f
e
v
e
n
t-
re
la
te
d
a
le
rt
s,
a
d
v
is
o
ri
e
s
a
n
d

212. u
p
d
a
te
s:
e
.g
.
re
sp
o
n
se
a
n
d
in
fe
c
ti
o
n
c
o
n
tr
o
l
a
n
d
e
x

213. p
o
su
re
p
ro
to
c
o
ls
;
c
a
se
d
e
fi
n
it
io
n
s;
v
a
c
c
in
a
ti
o
n
p
ri
o

214. ri
ty
g
ro
u
p
s;
v
a
c
c
in
e
e
ffi
c
a
c
y
in
fo
rm
a
ti
o
n
;
e
m
e
rg
e
n
c

215. y
w
a
iv
e
r
in
fo
rm
a
ti
o
n
H
1
N
1
v
a
c
c
in
a
ti
o
n
p
ro
v
id
e
rs

216. (m
e
d
ic
a
l
p
ro
fe
ss
io
n
a
ls
,
L
H
D
s,
h
e
a
lt
h
fa
c
il
it
ie
s
a
n
d
o
th

217. e
r
o
rg
a
n
iz
a
ti
o
n
s
a
d
m
in
is
te
ri
n
g
H
1
N
1
v
a
c
c
in
e
to
ta

218. rg
e
te
d
p
ri
o
ri
ty
p
o
p
u
la
ti
o
n
s)
T
a
rg
e
te
d
in
d
iv
id
u
a
l
a
n
d

219. m
a
ss
c
o
m
m
u
n
ic
a
ti
o
n
o
f
in
fo
rm
a
ti
o
n
,
u
p
d
a
te
s
a
n
d

220. a
d
v
is
o
ri
e
s
re
la
te
d
to
th
e
n
o
v
e
l
in
fu
e
n
z
a
v
a
c
c
in
e
a
d

221. m
in
is
tr
a
ti
o
n
c
a
m
p
a
ig
n
:
e
.g
.
o
rd
e
ri
n
g
,
o
rd
e
r
st
a
tu
s,
re

222. p
o
rt
in
g
o
f
a
d
m
in
is
te
re
d
d
o
se
s,
p
ri
o
ri
ty
g
ro
u
p
a
d
m
in
is
tr

223. a
ti
o
n
,
a
n
d
a
ll
o
c
a
ti
o
n
p
ro
to
c
o
ls
P
u
b
li
c
h
e
a
lt
h
in
te

224. rv
e
n
ti
o
n
:
st
a
te
w
id
e
v
a
c
c
in
e
c
a
m
p
a
ig
n
:
m
e
d
ic
a
l
c
o
u

225. n
te
rm
e
a
su
re
m
a
n
a
g
e
m
e
n
t,
v
a
c
c
in
e
o
rd
e
ri
n
g
,
m
a
n
a

226. g
e
m
e
n
t,
d
is
tr
ib
u
ti
o
n
,
a
d
m
in
is
tr
a
ti
o
n
a
n
d
re
p
o
rt
in
g
H

227. 1
N
1
v
a
c
c
in
a
ti
o
n
p
ro
v
id
e
rs
o
rd
e
ri
n
g
v
a
c
c
in
e
R
e
g
is

228. te
r
to
o
rd
e
r
v
a
c
c
in
e
,
p
la
c
e
v
a
c
c
in
e
o
rd
e
rs
,
re
c
e
iv
e

229. v
a
c
c
in
e
a
ll
o
c
a
ti
o
n
in
fo
rm
a
ti
o
n
,
c
h
e
c
k
o
rd
e
r
st
a
tu
s

230. V
a
c
c
in
e
o
rd
e
ri
n
g
a
n
d
m
a
n
a
g
e
m
e
n
t
sy
st
e
m
(V
O
M
S
)

231. M
e
d
ic
a
l
p
ra
c
ti
ti
o
n
e
r
o
r
p
ra
c
ti
c
e
o
r
h
e
a
lt
h
fa
c
il
it

232. y
a
g
g
re
g
a
te
a
d
m
in
is
te
re
d
d
o
se
s
re
p
o
rt
in
g
W
e
e
k
ly
re
p

233. o
rt
in
g
o
f
a
g
g
re
g
a
te
v
a
c
c
in
e
d
o
se
s
a
d
m
in
is
te
re
d
v
ia

234. p
h
o
n
e
o
r
w
e
b
a
p
p
li
c
a
ti
o
n
b
y
p
ra
c
ti
ti
o
n
e
rs
a
n
d
h
e

235. a
lt
h
fa
c
il
it
ie
s
fo
r
re
p
o
rt
in
g
p
ri
o
ri
ty
p
o
p
u
la
ti
o
n
g
ro
u
p
v

236. a
c
c
in
a
ti
o
n
s
M
e
d
ic
a
l
p
ra
c
ti
ti
o
n
e
r
o
r
p
ra
c
ti
c
e
p
a

237. ti
e
n
t-
le
v
e
l
a
d
m
in
is
te
re
d
d
o
se
s
re
p
o
rt
in
g
R
e
p
o
rt
n
u
m

238. b
e
rs
o
f
p
a
ti
e
n
t-
le
v
e
l
v
a
c
c
in
a
ti
o
n
s
fr
o
m
p
ro
v
id
e
r

239. o
ffi
c
e
b
a
se
d
se
tt
in
g
s
N
e
w
Y
o
rk
S
ta
te
Im
m
u
n
iz
a
ti
o
n
In

240. fo
rm
a
ti
o
n
S
y
st
e
m
(N
Y
S
II
S
)
L
H
D
C
li
n
ic
s/
P
o
in
ts
o
f
D

241. is
p
e
n
si
n
g
(P
O
D
s)
R
e
p
o
rt
n
u
m
b
e
rs
o
f
p
a
ti
e
n
t-
le
v
e

242. l
v
a
c
c
in
a
ti
o
n
e
v
e
n
ts
a
n
d
in
fo
rm
a
ti
o
n
a
t
c
o
u
n
ty
-b
a

243. se
d
m
a
ss
v
a
c
c
in
a
ti
o
n
c
li
n
ic
s
C
li
n
ic
D
a
ta
M
a
n
a
g
e

244. m
e
n
t
S
y
st
e
m
(C
D
M
S
)
730 I. J. Gotham et al.
123
T
a
b
le
3
c
o
n
ti
n
u
e
d

245. P
H
E
P
fu
n
c
ti
o
n
a
n
d
d
a
ta
/i
n
fo
rm
a
ti
o
n
so
u
rc
e
s
A
c
ti

246. v
it
ie
s
su
p
p
o
rt
in
g
P
H
E
P
re
sp
o
n
se
H
C
S
in
fo
rm
a
ti
o
n
sy
st
e
m

247. H
o
sp
it
a
l,
n
u
rs
in
g
h
o
m
e
a
n
d
a
d
u
lt
c
a
re
h
e
a
lt
h
c
a
re

248. w
o
rk
e
rs
A
ss
e
ss
v
a
c
c
in
a
ti
o
n
ra
te
s
fo
r
se
a
so
n
a
l
a
n
d
n

249. o
v
e
l
in
fl
u
e
n
z
a
a
m
o
n
g
h
e
a
lt
h
c
a
re
w
o
rk
e
rs
a
t
h
e

250. a
lt
h
fa
c
il
it
ie
s
H
E
R
D
S
—
h
o
sp
it
a
l,
n
u
rs
in
g
h
o
m
e
a
n
d

251. a
d
u
lt
c
a
re
fa
c
il
it
y
in
st
a
n
c
e
s
S
ta
te
e
x
e
c
u
ti
v
e
d
e
c

252. is
io
n
m
a
k
e
rs
a
n
d
in
c
id
e
n
t
m
a
n
a
g
e
m
e
n
t
st
a
ff
A
ll
o

253. c
a
te
li
m
it
e
d
su
p
p
li
e
s
o
f
e
v
e
n
t-
re
la
te
d
v
a
c
c
in
e
to
fi
ll
,

254. o
r
p
a
rt
ia
ll
y
fi
ll
,
p
ro
v
id
e
r
o
rd
e
rs
b
a
se
d
o
n
g
e
o
g
ra
p
h

255. ic
lo
c
a
ti
o
n
,
c
o
v
e
ra
g
e
o
f
p
ri
o
ri
ty
p
o
p
u
la
ti
o
n
s
se
rv
e

256. d
b
y
p
ro
v
id
e
rs
,
o
rd
e
r
h
is
to
ry
a
n
d
m
u
lt
ip
le
o
th
e
r
e
v
e

257. n
t
a
n
d
d
is
e
a
se
-r
e
la
te
d
fa
c
to
rs
V
O
M
S
S
ta
te
in
c
id
e
n
t

258. m
a
n
a
g
e
m
e
n
t
st
a
ff
a
n
d
L
H
D
s
T
ra
c
k
in
g
,
re
p
o
rt
in
g
a

259. n
d
in
v
e
n
to
ry
o
f
m
e
d
ic
a
l
c
o
u
n
te
rm
e
a
su
re
s,
e
q
u
ip
m
e

260. n
t
a
n
d
su
p
p
li
e
s
d
e
p
lo
y
e
d
d
u
ri
n
g
h
e
a
lt
h
e
m
e
rg
e
n
c

261. y
fr
o
m
st
a
te
a
n
d
fe
d
e
ra
l
st
o
c
k
p
il
e
s
M
e
d
ic
a
l
e
m
e

262. rg
e
n
c
y
re
sp
o
n
se
in
v
e
n
to
ry
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An informatics framework for public health information systems
731
123
However, no system existed to support transactional placement
of vaccine orders,
order and inventory tracking, and reporting for orders placed to
the CDC. Further,
there was no integrated allocation system to implement the
state’s requirements for
distribution and reporting. The situational awareness and
decision support
capabilities of the HCS also had to be attuned to this
information flow in order to
allow decision makers to assess need based on federally

286. mandated priority
populations, place orders for vaccine supply, and report the
number of vaccines
administered.
As described in our definition of information systems and our
informatics
framework (Fig. 1), people and processes form an important
infrastructure
component of each paradigm. Our model informatics framework
includes a
governance process which informs an agile informatics team of
the needs of the
enterprise, the team being tasked with the responsibility of
developing and
implementing the information system to meet them.
Thus, NY State maintains a staffing infrastructure of subject
matter experts in
technology, project management, informatics and health
knowledge domains who
make up an informatics team (see Fig. 1 for roles on that team).
That team was
tasked with the responsibility for design, development, and
implementation, by

287. October 1, 2009, of the systems required to order, manage, track
inventory, and
report the status of vaccination campaigns. Additionally, all
data feeds from these
new systems and existing information systems had to be
integrated into the
executive dashboard (Tables 2, 3) to enable a common
operational picture to
provide situational awareness as well as decision support in
ordering, prioritizing
and distributing vaccine among the NYS population.
The governance structure was centered around a series of Health
Knowledge
domain executive workgroups created to cover all programmatic
information
system needs for the response. The Informatics team
participated as an integral
component on all of these programmatic workgroups and was
tasked with the
responsibility of developing the informatics component of the
plan: a compre-
hensive approach to support (1) incident management; (2)
vaccination campaign;
(3) epidemiologic surveillance; (4) monitoring health care

288. facility status,
resource utilization and availability, surge capacity; (5)
community mitigation;
(6) alerting and communication; (7) situational awareness and
decision support
(see Tables 2, 3).
Executive workgroup products–objectives, response triggers,
guidance, policy,
protocols, and operational documents–were created and posted
within a Virtual
Health Operations Center (VHOC) within the HCS system
(Table 3). The VHOC
information system provided a vehicle to share and collaborate
on plan development
with external response partners within the information exchange
community of the
HCS. The VHOC also supported the IMS process through
electronic tracking of
assignments and collaborative production of daily reports
(Situation Reports) for
executive consumption.
A key deliverable of the Informatics team was to formulate a
cohesive and

289. comprehensive Master Data Management Plan (MDMP). An
MDMP was essential
to establishing a single integrated and authoritative source of
information to the data
layer services that would support the Information Systems to be
used in the response
732 I. J. Gotham et al.
123
(e.g. see Figs. 1, 2). This effort was largely focused on
identifying the data elements
that were well defined and reliable; used a standard vocabulary;
could be obtained
without overburdening the data providers; were needed to
support state and local
executive decision making and situational awareness and to
present a common
operational picture to the IMS staff; and would lead to
information products that
offered value back to the data provider. Defining data sharing
and access rules and
other key metadata elements was also included in the plan. A
data dictionary was

290. developed and linked to electronic data collection templates for
deployment in the
HERDS systems. Each template was tailored to the needs of
agreed-upon scenarios
of disease severity.
The informatics forum for developing the MDMP included
participants from
organizations that cross-cut the information exchange
community on the HCS:
NYSDOH health care and public health subject matter experts
(SMEs), New York
City Department of Health and Mental Hygiene (NYCDOHMH)
local public health
agency programs, LHDs, hospital associations, and long-term
care facilities. The
result of this effort was a well-defined and realistic MDMP that
was supported by
the health care and local health response partners. The MDMP
also addressed the
need for school closure and absenteeism surveillance. The
informatics workgroup
used a similar approach working with NYSDOH
epidemiologists, the NYS
Education Department, LHDs, and representatives from schools

291. and school districts
to design a plan for schools to report absenteeism via the
HERDS information
system. The data collected from these reporting streams would,
as part of the plan,
be integrated into the HCS executive dashboard visualization
system to provide a
common operational picture and situational awareness to
executive staff and the
IMS.
The informatics team engaged an agile project management
approach to
developing and implementing a Vaccine Ordering and
Management System
(VOMS). The process started with a ‘‘top-to-bottom’’ business
analysis of existing
vaccine ordering and distribution protocols and procedures to
gather requirements
and assess how technology could improve workflow and
streamline the process and,
further, allow the flexibility needed for rapid responses to
changes in vaccine supply
and demand at the national, state, or local level. The ability to
react to, and

292. accommodate, changes in the VOMS system was essential as the
vaccination
campaign itself presented complex and rapidly evolving state
and federal
requirements. An overview of the information and process flow
of the vaccine
campaign is shown in Fig. 3. VOMS requirements dictated that
the system must:
• Allow vaccination provider organizations to register
electronically and to
acknowledge their agreement to federally mandated conditions,
place orders,
receive order status updates, and make changes in orders online
• Allow local health departments to assess provider rankings in
priorities
• Support a data-driven allocation process
• Place orders with the Centers for Disease Control
• Accept reports from providers of vaccine doses administered
to priority
populations as identified in federal guidance
An informatics framework for public health information systems
733
123

293. • Be operational before October 19, 2009, when supplies of the
vaccine would be
available to fill state orders
The third phase involved implementation of the response plan,
which included the
vaccine campaign as a public health intervention to control the
spread of the disease
(September 2009 to January 2010). A common operational
picture of disease
surveillance data, health care facility status and resources,
vaccine ordering and
administration status, and infection control actions had to be
made rapidly available
to policy makers and response partners. The influenza vaccine
countermeasure
would be made available to vaccination providers according to
the federal
government’s prioritization recommendations. State allocation
decisions would be
informed by multiple data sources, including: surveillance,
healthcare status, and
reports of administered doses from mass clinics, school-based
clinics, hospitals,
community health centers, and private providers.

294. 5.1 Phase 3: implementation of information systems supporting
the revised
response plan and vaccine countermeasure campaign
The third phase involved implementation of the revised Phase 2
response plan. The
goal was to establish and sustain a ‘long-term’ public health
intervention campaign
designed to control the spread of the disease (September 2009
to January 2010). The
plan dictated the absolute need for decision makers and
response partners across the
HCS community to have real-time access to a common
operational picture of
disease surveillance data, health care facility status and
resources, vaccine ordering
and administration status, and infection control actions. The
influenza vaccine
orders placed with the CDC by the States would be made
available to vaccination
providers according to the federal government’s prioritization
recommendations and
the States’ allocation plans. Therefore, NY State orders to the
CDC for vaccine and
its allocation supplies must be informed by multiple data

295. sources, including:
surveillance, healthcare status, and reports of administered
doses from mass clinics,
school-based clinics, hospitals, community health centers, and
private providers.
5.1.1 Epidemiologic surveillance information systems
Using the MDMP, NYS implemented enhanced influenza
surveillance activities by
leveraging its existing information systems tracking both
severity and extent of both
novel influenza and seasonal influenza (see Tables 2, 3). These
systems included:
Electronic lab reporting system, HERDS, communicable disease
case reporting, and
syndromic surveillance. Thus, given the the long history of
HCS’s information
systems, surveillance data collected in previous years could be
used as baselines for
comparison against any changes in seasonal trends in activity or
patient attributes in
the data collected during Phase 3 (see Fig. 4).
The HERDS school surveillance information system was
activated to provide a

296. tool for schools and LHDs to collect and track absenteeism data
in a consistent way
across the state, to facilitate monitoring of potential increases in
illness, and to
provide objective data to support local decision making
regarding possible
734 I. J. Gotham et al.
123
community mitigation actions, such as school closures. All
related data feeds from
these surveillance activities were integrated into the executive
dashboard decision
support system, informing the vaccination campaign as well as
assisting in
providing a common operational picture of disease extent across
the state (see
Figs. 4, 5).
5.1.2 Information systems monitoring and tracking health care
facility status,
resource utilization and availability, surge capacity
The MDMP called for a staged approach to monitoring health
facility status and

297. resource utilization or shortfalls across the continuum of acute
and long-term care
facilities, based on severity of the disease (Tables 2, 3). The
intent was to monitor
status, assess the level of ‘‘stress’’ the facilities were
experiencing due to hospital or
ED admissions, and activate IMS intervention processes to
allocate physical or
staffing resources if needed to help maintain the ability of
facilities to provide
routine care or respond to even greater demands. The HERDS
system was used to:
• Track bed availability and utilization, by service category
(e.g., adult/pediatric
ICU, medical/surgical, monitored, isolation), in comparison to
the total staffed
beds at health care facilities
Fig. 3 Interrelation and Information Flow between Information
Systems Supporting the Vaccination
Campaign
An informatics framework for public health information systems
735
123

298. • Track supplies of personal and respiratory protective
equipment
• Track critical life support equipment (e.g., ventilators)
• Track pharmacy supplies
• Assess facility stress levels as indicated by activation of surge
plans, emergency
operations centers, diversion status, cancellation of elective
procedures, etc.
• Assess health care worker shortages
The data feeds from both acute care and long-term care
facilities were also
integrated into the executive dashboard (see Fig. 5) to inform
the IMS leads and
also the vaccination campaign.
5.1.3 Information systems supporting the vaccination campaign
The complex data and workflow needed to support the VOMS
system as well as
other supportive information systems (Fig. 3) were integrated
using the SOA and
reusable core services within NY’s framework (Figs. 2, 3). This
allowed NY State
to effectively take orders for vaccine from providers, allocate
them according to
ACIP priority groupings, place orders with the CDC and track

299. all portions of the
transaction. Using the executive dashboard decision support
system (Fig. 5) with
information integrated in real time from the provider
registrations and orders from
allocated H1N1 vaccine doses and types from the CDC,
NYSDOH was able to
allocate the available doses of vaccine to appropriate providers
and target the groups
recommended by ACIP to receive vaccine.
Once allocated, vaccine orders were transmitted electronically
to CDC for
distribution to providers either directly from CDC or via state
or local health
departments. NYSDOH also automatically tracked each vaccine
shipment and
Fig. 4 Hospital patients testing positive for influenza virus,
New York State, October 2007–May 2010
736 I. J. Gotham et al.
123
provided information to state and local health officials for
distribution planning and

300. tracking and to providers via the Order History Report for
immunization scheduling
and coordination with patients. After vaccine was administered,
providers were
required to report the number of administered doses via one of
three mechanisms:
H1N1 Vaccine Administered Doses Reporting System, which
utilized a dual phone
and web data entry interface, Clinical Data Management System
for mass
Fig. 5 Example of NYSDOH Executive Situational Awareness
Dashboard and Data Visualizer System
An informatics framework for public health information systems
737
123
vaccination clinics hosted by local health departments, and NYS
Immunization
Information System (Tables 2, 3). If providers needed to
redistribute vaccine to
others, they could also report through a web interface so the
data could be used for
both allocation and tracking purposes. Based on the MDMP, all

301. information from
these systems were integrated into a centralized data layer so
they could be analyzed
and visualized for operational decision support and situational
awareness via the
executive dashboard and other visualization tools (Fig. 5).
5.1.4 Situational awareness and decision support
The MDMP developed by the Informatics team provided the
framework for assuring
the effectiveness of data-driven decisions throughout the Phase
3 response. The
Executive Dashboard and Data Visualizer tool (Tables 2, 3)
provided a single,
seamless, and highly visual interactive interface for executive
decision makers and
IMS managers to have access to a common operational picture
based on
standardized and agreed-upon data elements and visual objects
(Fig. 5). The
dashboard provided summary information as well as interactive
drill-down into
aggregated and time-series data views from HERDS, laboratory
surveillance

302. systems, syndromic data, hospital resource availability, bed
utilization, school
absenteeism, and vaccine ordering and administration for state
and local health
officials.
Access to these data informed the vaccine allocation process,
providing all
information necessary to formulate, execute, and communicate
executive and
operational decisions in vaccine management, allocation, and
distribution across
providers, jurisdictions, and DOH programs. Of key importance
was that all
decision makers and supporting analysts used a common
operational picture and
standard data sets on which to base their decisions and actions.
Resulting data-
driven executive policies, vaccine administration and reporting
procedures, and
other patient care–related information regarding the vaccination
campaign were
flash-transmitted to a cohort of some 5,500 vaccination provider
organizations via
the IHANS system (Tables 2, 3). Information about the response

303. and vaccination
campaign was regularly made available to the HCS health
information exchange
community via the event-specific website (Tables 2, 3).
Information on the website
included daily vaccine campaign status reports of doses ordered,
allocated, shipped,
and administered for all local health departments.
6 Value of an informatics framework and information systems
in supporting
emergency preparedness and response
We have discussed the role of a model Informatics Framework
and the information
systems it encompasses in providing value throughout the cycle
of Public Health
Emergencies: Preparedness, Response and Recovery (Figs. 1,
2). The final stage,
recovery, is considered in Sect. 4. In this section we review
some of the beneficial
outcomes of this Framework.
738 I. J. Gotham et al.
123

304. 6.1 Preparedness benefit: well established and routinely used
informatics
framework
NY State’s existing informatics framework conveyed the
following advantages in
responding to the novel influenza event:
• The dual use nature of the HCS and its information systems
entrained and
cultured a community of electronic heath information exchange
partners that
cross-cut health organizations across the state. Thus all needed
response partners
were already using the HCS systems and their role and contact
information was
captured in the communications directory at the time of the
event (Tables 1, 2, 3).
• Lessons learned from a history of responding to health events
such as West Nile
Virus, 9/11, natural disasters, and health care resource shortages
allowed
systems to evolve to support routine and emergency use (e.g.
Gotham et al.
2001, 2007, 2008). Thus NY State had the information systems
in place to

305. respond immediately to the health event.
• existing information systems not only allowed for rapid
response to the event but
also provided a history of baseline data for monitoring changes
in trends during
the event.
• Ongoing exercises and drills that use and test the informatics
framework and its
information systems resulted in both user and information
system preparedness
to respond to the health event (see Gotham et al. 2010).
• A governance process and an existing and experienced team of
experts in
informatics, health domain subjects, project management and
information
technology enabled NY State to rapidly develop and modify
information
systems and MDMP to meet the information and planning needs
of the longer
term response to the health event. The existence of the HCS
information
exchange community provided a source of health organizations
able to
contribute to the MDMP as well as provide input into the
development of

306. new information systems based on their knowledge and use of
the existing HCS
systems.
6.2 Response benefit: health alerting and notification: rapid
communication
of critical event-related information across response partners
The Integrated Health Alerting and Notification System
provides general and
targeted health alerting and notification, using multiple
communications modalities:
automated phone, cell, e-mail notifications with
acknowledgements (Tables 2, 3;
Fig. 2) (see Le et al. 2010). Routine health alerting drills are
conducted with local
health departments and health facilities assure proficiency in its
use (see Gotham
et al. 2007, 2010; Le et al. 2010). The IHANS serves multiple
purposes during an
emergency response: (1) notifying targeted organizations as to
new health alert
postings or materials posted on the event website within the
HCS (see below); (2)
direct distribution of documents and information to targeted
HCS organizations; (3)

307. notifying targeted organizations of surveys activated within the
HERDS systems. In
the initial weeks of the novel influenza response (April 24–June
1, 2009) the IHANS
An informatics framework for public health information systems
739
123
was used to transmit 309 separate event-related notifications to
an aggregate total of
396,014 users. The targeted organizations included LHDs,
hospitals, nursing homes,
adult and home care organizations. Table 4 presents
representative examples of
average time to alert pickup by key HCS organizations during
the initial phases of
the PHEP response.
6.3 Response and recovery benefit: decision support, situational
awareness:
informing decision-makers, response partners and the health
information
exchange community in general

308. Situational awareness for the HCS community was provided via
two mechanisms:
(1) health alert postings within the HCS Health Alert Network
(HAN) Viewer
system; and (2) an event-specific website within the HCS portal
itself. IHANS is
used to notify targeted HCS groups that new postings are
available. As described
earlier and indicated in Table 1, the HCS portal is a diverse
information exchange
platform. The NYSDOH response protocol for a health event is
to establish an
event-specific website within the HCS portal system (Tables 2,
3; Gotham et al.
2010). This site is the focal point for access to all event-related
postings,
applications, information, and data. This includes links to the
HCS Health Alert
Viewer as well as to collections of electronic documents. The
documents posted in
the HAN Viewer and the website included case definitions,
infection control
protocols, clinical and treatment guidance, specimen handling
and biosafety

309. procedures, laboratory testing protocols; school closing and
surveillance recom-
mendations; guidance for EMS workers and facility-specific
guidance for long-term
care, educational, child care, and correctional facilities and
summer camps.
Between April 24 and June 1, 2009, some 482,681 event-related
documents were
downloaded by 32,185 distinct HCS users from the Alert Viewer
and event website.
Table 5 presents the document access distribution among key
organizations from
April 24 through December 31, 2009. Over this period of time,
over 45,000 users
downloaded approximately 1.3 million documents from HCS.
On average, 70 % of
these users were repeat users, defined as having downloaded
materials on 3 or more
separate days. LHDs were the highest user group in terms of
both volume of
documents downloaded and percent of repeat users. Medical
practitioners as a group
constituted the greatest number of users accessing event-related
materials.

310. 6.4 Preparedness, response and recovery benefit: flexible and
dynamic
surveillance, visualization and reporting systems deployed and
in routine
use across the organizations within the health information
exchange
community: immediate responsiveness to information needs for
any event
or routine health program initiative
The HERDS system is completely dynamic and does not require
programing to
develop and deploy information gathering and reporting
applications (see Gotham
et al. 2007). This information system was used throughout the
response to support a
wide array of ongoing and customized information and data
collection needs
dictated by the event and the phase of the response to the event.
It supported event-
740 I. J. Gotham et al.
123
related data reporting required for epidemiologic surveillance,

311. reporting of resource
and bed availability, assessment of facility stress level due to
patient influx, and
oversight of vaccination rates in the healthcare setting (Tables
2, 3). The system was
used for data exchange by facilities ranging from acute care
hospitals to long-term
care facilities and schools, and it simultaneously supported
customized surveillance
needs of the NYCDOHMH. As HERDS has been in use since
2003–2004 for
periodic reporting of bed availability, critical assets, and
seasonal influenza testing
by hospitals, the NYSDOH had historical trend data to provide
baseline information
for comparison against the evolving seasonal and H1N1
influenza patterns. For
example, hospital reporting of patient admissions with
laboratory-confirmed
influenza (any type) showed a dramatic shift in pattern during
the spring and fall
of 2009 over previous years (Fig. 4). The integrated information
architecture of the
HCS system (Figs. 1, 2) assures that the diverse data streams

312. flow into a central data
repository and are available for visualization and provision of a
common operational
picture via a single dashboard system (Fig. 5; see also Gotham
et al. 2010). Table 6
presents the composite access transactions against HERDS
instances for hospitals,
nursing homes, and schools from April 24 through December
31, 2009. Over this
period of time, there were over 6.6 million access transactions
(submitting data or
retrieving reports) by over 14,000 users. On average, across all
organizations 43 %
of these users were repeat users, accessing the system on 3 or
more days.
6.5 Preparedness and response benefit: existing informatics
framework assures
rapid, effective response to new information systems needs:
case study-
vaccine ordering and administration system
The Vaccine Ordering and Management System (VOMS) was
required to manage
the ordering and distribution of vaccine, short in supply, and to
assure that the

313. majority of organizations providing vaccinations to the
federally designated priority
groups met certain requirements. The information system
required linkage of a
complex information and process workflow (Fig. 3). Physicians
were required to
register to order the H1N1 vaccine, to report the number of
patients they serve in the
priority population groups, and to attest their agreement
(electronically) to a
federally required vaccine receipt agreement. It was critical that
the majority be
registered and able to place orders in advance of the availability
of vaccine (October
19, 2009) to allow NYSDOH executive decision makers the
ability to execute the
allocations according to provider attributes (e.g. priority
populations served) and
other critical information available from the common
operational picture presented
in the dashboard system (Figs. 2, 4, 5).
A shortage of vaccine and delays in production at the onset of
the campaign

314. created unanticipated demand and increased pressure to
distribute limited supplies
of vaccines. These events had a significant impact on planning
assumptions. Rapid
and frequent changes in business rules were required during the
development of the
Vaccine Ordering and Management System (VOMS).
Nevertheless, given the rapid
development environment within NYS informatics framework,
combined with the
adoption of agile methodology, the process—requirement
gathering, business rule
definition, and technical development of VOMS—was
completed in only 1 month.
An informatics framework for public health information systems
741
123
T
a
b
le
4
E
x

315. a
m
p
le
h
e
a
lt
h
a
le
rt
re
sp
o
n
se
ra
te
s
fo
r
n
o
v
e
l
in
fl
u
e
n
z
a

316. (H
1
N
1
)
e
v
e
n
ts
E
x
a
m
p
le
o
n
e
E
x
a
m
p
le
tw
o
E
x
a

317. m
p
le
th
re
e
E
x
a
m
p
le
fo
u
r
E
x
a
m
p
le
fi
v
e
E
x
a
m
p
le

318. si
x
T
a
rg
e
t
o
rg
a
n
iz
a
ti
o
n
L
H
D
s
H
o
sp
it
a
ls
L
H
D
s

319. N
u
rs
in
g
H
o
m
e
s
L
H
D
s
H
o
m
e
H
e
a
lt
h
A
g
e
n
c
ie
s
D

320. a
te
/t
im
e
in
it
ia
te
d
A
p
ri
l
2
8
,
2
0
0
9
1
0
:1
0
a
.m
.
M
a

321. y
1
,
2
0
0
9
1
5
:3
2
p
.m
.
M
a
y
2
,
2
0
0
9
1
5
:1
0
p
.m
.

322. M
a
y
1
,
2
0
0
9
8
:2
1
a
.m
.
A
p
ri
l
2
6
,
2
0
0
9
1
8
:5
9
p
.m

323. .
A
p
ri
l
3
0
,
2
0
0
9
2
0
:2
8
p
.m
.
P
u
rp
o
se
:
In
it
ia
te

324. L
H
D
/N
Y
S
D
O
H
e
p
id
e
m
io
lo
g
-i
c
a
l
b
ri
e
fi
n
g
s
A
c
ti
v
a
te

325. H
E
R
D
S
S
u
rv
e
y
B
a
se
li
n
e
P
P
E
a
n
d
S
u
p
p
li
e
s
A
le
rt
L
H

326. D
s
to
S
N
S
a
ss
e
t
d
is
tr
ib
u
ti
o
n
G
u
id
a
n
c
e
:
P
a
ti
e
n
t

327. a
n
d
S
ta
ff
C
a
re
in
L
o
n
g
T
e
rm
C
a
re
S
e
tt
in
g
fo
r
‘‘
S

328. w
in
e
In
fl
u
e
n
z
a
’’
In
it
ia
l
‘‘
S
w
in
e
F
lu
’’
b
ri
e
fi
n
g
w
it
h

329. L
H
D
O
ffi
c
ia
ls
a
n
d
h
o
sp
it
a
ls
N
Y
S
D
O
H
S
w
in
e
In
fl
u
e

330. n
z
a
A
(H
1
N
1
)
in
fo
rm
a
ti
o
n
a
n
d
Q
/A
se
ss
io
n
s
fo
r
L
T

331. C
p
ro
v
id
e
rs
U
rg
e
n
c
y
le
v
e
l:
A
le
rt
;
h
ig
h
e
st
u
rg
e
n
c

332. y
A
le
rt
;
h
ig
h
e
st
u
rg
e
n
c
y
A
le
rt
;
h
ig
h
e
st
u
rg
e
n
c
y

333. A
d
v
is
o
ry
H
ig
h
A
d
v
is
o
ry
A
d
v
is
o
ry
C
o
n
ta
c
t
M
o
d
e
:

334. P
h
o
n
e
,
E
m
a
il
P
h
o
n
e
,
E
m
a
il
P
h
o
n
e
,
E
m
a
il
E
m

335. a
il
P
h
o
n
e
;
E
m
a
il
E
m
a
il
C
o
n
fi
rm
a
ti
o
n
ra
te
:
1
0

336. 0
%
;
L
H
D
s
(5
9
);
N
Y
C
D
O
H
M
H
;
N
Y
S
D
O
H
re
g
io
n
s
(6
);
9

337. 6
%
;
N
Y
S
h
o
sp
it
a
ls
(2
5
6
/2
6
7
)
1
0
0
%
;
L
H
D
s
(5
9
);
N
Y

338. C
D
O
H
M
H
;
N
Y
S
D
O
H
re
g
io
n
s
(6
)
9
2
%
N
u
rs
in
g
H
o
m

339. e
s
(5
9
7
/
6
5
2
)
1
0
0
%
L
H
D
s
(5
9
);
N
Y
C
D
O
H
M
H
;

340. N
Y
S
D
O
H
re
g
io
n
s
(6
);
9
1
%
h
o
sp
it
a
ls
(2
0
0
/2
1
9
)
8
1

341. %
H
o
m
e
H
e
a
lt
h
A
g
e
n
c
ie
s
(2
3
0
/
2
8
3
)
C
o
n
fi
rm

342. a
ti
o
n
st
a
ts
:
M
e
a
n
;
m
in
;
m
a
x
;
m
o
d
e
1
0
;
4
;
5
0
;

343. 6
(m
in
u
te
s)
6
2
;
1
3
;
2
9
1
;
1
9
(m
in
u
te
s)
9
;
4
;
2
5
;
4

344. (m
in
u
te
s)
7
0
;
1
0
;
5
8
9
;
1
3
(m
in
u
te
s)
2
4
7
;
1
0
;
1
0
4
8

345. ;
1
6
6
(m
in
u
te
s)
6
0
4
;
1
5
;
1
0
0
0
;
N
/A
(m
in
u
te
s)
742 I. J. Gotham et al.

346. 123
T
a
b
le
4
c
o
n
ti
n
u
e
d E
x
a
m
p
le
o
n
e
E
x
a
m
p
le
tw

347. o
E
x
a
m
p
le
th
re
e
E
x
a
m
p
le
fo
u
r
E
x
a
m
p
le
fi
v
e
E

348. x
a
m
p
le
si
x
R
o
le
s
a
le
rt
e
d
:
L
H
D
:
C
o
m
m
is
si
o
n
e
r/
P
H

349. D
ir
;
P
H
E
P
E
p
id
e
m
io
lo
g
y
C
o
n
ta
c
t;
P
H
E
P
P
ri
m
a
ry
C

350. o
n
ta
c
t;
C
o
m
m
u
n
ic
a
b
le
D
is
e
a
se
In
v
e
st
ig
a
ti
o
n
S
ta
ff
;

351. L
e
a
d
E
p
i;
D
ir
.
D
is
e
a
se
C
o
n
tr
o
l;
D
ir
P
a
ti
e
n
t
S
e
rv
ic

352. e
s;
N
Y
S
D
O
H
R
e
g
io
n
:
Im
m
u
n
iz
a
ti
o
n
C
o
o
rd
;
L
e
a
d

353. E
p
i;
R
e
g
io
n
a
l
E
p
i;
D
ir
.,
D
is
e
a
se
C
o
n
tr
o
l
H
o
sp
it
a
l:

354. C
h
ie
f
E
x
e
c
u
ti
v
e
O
ffi
c
e
r;
B
io
te
rr
o
ri
sm
C
o
o
rd
in
a
to
r;
D
e

355. si
g
n
a
te
d
P
h
a
rm
a
c
is
t;
E
m
e
rg
e
n
c
y
R
e
sp
o
n
se
C
o
o
rd

356. ;
H
E
R
D
S
D
a
ta
M
a
n
a
g
e
r;
H
E
R
D
S
D
a
ta
R
e
p
o
rt
e
r;
H
E
R

357. D
S
S
u
rv
e
y
R
e
p
o
rt
e
r
L
H
D
:
C
o
m
m
is
si
o
n
e
r/
P
H
D

358. ir
;
S
N
S
,
C
o
o
rd
;
O
n
-
D
u
ty
P
H
O
ffi
c
e
r;
N
Y
S
D
O
H

359. R
e
g
io
n
:
D
ir
,
R
e
g
io
n
a
l
O
ffi
c
e
N
u
rs
in
g
H
o
m
e
A
d
m
in

360. is
tr
a
to
r;
D
ir
e
c
to
r,
N
u
rs
in
g
;
E
m
e
rg
e
n
c
y
R
e
sp
o
n
se

361. C
o
o
rd
in
a
to
r;
H
P
N
C
o
o
rd
;
N
u
rs
in
g
H
o
m
e
D
a
ta
R
e
p

362. o
rt
e
r;
P
la
n
t
M
a
n
a
g
e
r
L
H
D
:
C
o
m
m
is
si
o
n
e
r/
P
u
b

363. li
c
H
e
a
lt
h
(P
H
)
D
ir
e
c
to
r
(D
ir
);
In
c
id
e
n
t
C
o
m
m
a
n
d

364. -
L
H
D
;
P
u
b
li
c
In
fo
rm
a
ti
o
n
O
ffi
c
e
r
N
Y
S
D
O
H
:
P
H

365. E
P
E
d
u
c
a
ti
o
n
/
T
ra
in
in
g
C
o
o
rd
;
P
H
E
P
C
o
o
rd
;
S
ta

366. te
H
A
N
C
o
o
rd
H
H
A
:
A
d
m
in
is
tr
a
to
r;
E
m
e
rg
e
n
c
y
P

367. re
p
a
re
d
n
e
ss
C
o
o
rd
;
H
P
N
C
o
o
rd
L
H
D
L
o
c
a
l
H
e
a
lt

368. h
D
e
p
a
rt
m
e
n
t,
N
Y
S
D
O
H
N
e
w
Y
o
rk
S
ta
te
D
e
p
a
rt
m
e

369. n
t
o
f
H
e
a
lt
h
,
N
Y
C
D
O
H
M
H
N
e
w
Y
o
rk
C
it
y
D
e
p
a
rt
m

370. e
n
t
o
f
H
e
a
lt
h
a
n
d
M
e
n
ta
l
H
y
g
ie
n
e
,
H
E
R
D
S
H
e
a
lt
h

371. E
m
e
rg
e
n
c
y
R
e
sp
o
n
se
D
a
ta
S
y
st
e
m
,
P
P
E
P
e
rs
o
n
a
l
P

372. ro
te
c
ti
v
e
E
q
u
ip
m
e
n
t,
S
N
S
S
tr
a
te
g
ic
N
a
ti
o
n
a
l
S
to
c
k
p
il

373. e
,
N
Y
S
N
e
w
Y
o
rk
S
ta
te
,
P
H
P
u
b
li
c
H
e
a
lt
h
,
D
ir
.
D
ir
e
c

374. to
r,
P
H
E
P
P
u
b
li
c
H
e
a
lt
h
E
m
e
rg
e
n
c
y
P
re
p
a
re
d
n
e
ss
,
E

375. p
i
E
p
id
e
m
io
lo
g
is
t,
C
o
o
rd
C
o
o
rd
in
a
to
r,
H
A
N
H
e
a
lt
h
A
le
rt

376. N
e
tw
o
rk
,
H
P
N
H
e
a
lt
h
P
ro
v
id
e
r
N
e
tw
o
rk
,
H
H
A
H
o
m
e
H
e
a

377. lt
h
A
g
e
n
c
y
An informatics framework for public health information systems
743
123
The process of registration and order placing for vaccine was
expedited by the fact
that 95 % of the vaccination provider organizations were
existing members of the
HCS system and had used it for other applications. Owing to the
existing HCS
infrastructure, its experienced user community, and the agility
of VOMS, approx-
imately 80 % of vaccine providers were registered in VOMS and
placing orders by
October 20, when H1N1 vaccine was available at the federal
level for distribution. As
shown in Fig. 6, a total of 5,509 provider organizations

378. registered over the course of
the event. Eighty percent of the providers had registered prior to
the deadline and had
placed orders with the state for some 750,000 doses. By the end
of the year the
providers had placed orders for nearly 13 million doses of
vaccine (Fig. 6).
7 Conclusions and lessons learned
The presence of an established integrated informatics
framework for health
information exchange and PHEP in NY State conveyed
significant advantages in
Table 5 H1N1 Influenza-related Documents Downloaded from
Event Website and Integrated Health
Alerting and Notification System (IHANS) by NYSDOH Health
Commerce System (HCS) Organizations
(April 24 through December 31, 2009)
Organization
type
Organizations
downloading
Documents downloaded

379. (total = 1,321,580)
Users downloading documents
(total = 45,172 repeat
users = 31,797)
Percent registered
with HCS
Percent total downloads Percent total
downloading
Percent
repeat users
Laboratories 73 2.7 5.9 72
Clinics 41 2.3 2.6 75
Adult care 82 14.9 9.5 85
Hospitals 100 14.0 12.0 80
LHDs 100 20.2 6.7 87
Medical
professionals
42 16.9 36.0 55