Report of the Subcommittee on System Requirements
Draft 4. 2.13.09
Participants
Advisory Committee Members:
Ron Manderscheid (subcommittee chair), Jonathan Fielding, Doug Evans, Patrick Remington and Lisa Iezzoni
External Members
From the CDC: Annie Archibold (on behalf of Anne Haddix)
From the National Center for Health Statistics: Richard Klein
Subcommittee Staff:
From ODPHP: Emmeline Ochiai, Jeanette Guyton-Krishnan, Carter Blakey
From NORC: Karen Harris, Chris Dymek, and Hilary Scherer
Purpose
The Subcommittee sought to articulate the content and the process for an approach to designing an online version of Healthy People that would become the primary vehicle for communicating health promotion and disease prevention objectives and interventions for the nation. This web-accessible database would supplement the current, paper-based version of Healthy People. The desired effects of creating an online version of Healthy People include extending access to Healthy People materials to a much broader range of audiences, increasing flexibility of use, and reducing the environmental impact of printed volumes.
Assumptions
The following assumptions were agreed upon by the Subcommittee:
Ø The online version should encompass fixed queries of Healthy People 2020 aggregate results. It would not offer custom queries of Healthy People micro-data.
Ø The online version should focus principally on applications for Primary Audiences identified by the User Group Subcommittee. (see Attachment A).
Ø Online applications for Secondary Audiences could be developed separately, especially through the Healthy People Network.
Ø All IT work undertaken in support of the Healthy People 2020 should be phased.
Ø The Advisory Committee should discuss a broader array of Healthy People IT applications at its January 2009 in-person meeting.
Approach
The Subcommittee engaged in a number of spirited discussions, and also conducted a review of approaches and processes used to develop information technology. Based on the conclusions of this work, the Subcommittee recommends that HHS adopt the approach described in “Online Project Development Principles” (Attachment B) and the brief “User Centered Design Principles.” (Attachment C) These documents recommend approaching IT development with clear definitions of project phases and their timeline, and, equally important, substantial user involvement.
It is the subcommittee’s belief that the incorporation of user input is essential to the successful development of an online version of Healthy People 2020. Focus groups should be utilized to gather input on how users want to employ the online tool, and what end-product they would want it to yield. Such user feedback should be the driving mechanism behind constructing a user interface, as well as the query capacity of the site.
The following discussion elaborates on some central ideas regarding site content. Two key issues must be solved to enable a user to find desired information quickly.
Ø First, the user’s request must be defined through a series of carefully crafted questions. A “nested” series of queries and sorts would allow the user to hone in on the data of interest. As the user progresses through a sequence of decisions, each question would be defined more narrowly. This sequential search would build an “external pointer” that correctly targets the desired data.
Ø Second, the data contained in the system should be organized in a relational manner that defines the empirical connections between particular data elements. These empirical connections would be defined using an elaborated Healthy People 2020 causal model that incorporates Interventions (i.e., policies and programs), Health Determinants, and Health Outcomes. The latter can be thought of as a relational data model.
The External Pointer
The following questions are suggestive of those that would be required to enable the external pointer to hone in on data that meet the user’s needs.
Ø Who is initiating the query? (i.e., who is the user?)
Does this query have a specific population focus? If so, what is the population?
Ø Does this query have a specific disease focus? If so, what is the disease?
Ø What type of information is desired from the query?
User categories should be defined through the categories of the Audience Matrix (see Attachment A);
Population categories for which data are available should be defined based on the “minimum template” for Healthy People 2010 (see Attachment D);
Specific disease categories should be based on disease areas named in the 28 focus areas of Healthy People 2010, as well as any additional categories that are defined by the Advisory Committee in coming months;
Categories for types of information to be provided should be defined broadly as Interventions, Health Determinants [causes], and Health Outcomes, or a combination of these factors.
Finally, the site must be accessible to persons with disabilities, and must be fully Section 508 compliant.
Some example questions are in Attachment E.
Draft User Interface
Although initial discussion has been held about a user interface, development of an actual interface should be informed by input from intended users of the interactive web site.
Two examples are shown immediately below. The first focuses upon a particular target population and is seeking information about a particular health determinant, obesity, related interventions (i.e., policies, programs, and information), and related health outcomes. The second focuses on a health determinant, physical activity, and is seeking information about variability across different populations, related interventions, and related health outcomes.
Example 1: Target Population Query
What is the prevalence of obesity in the U.S. among non-Hispanic, Black/African American adults ages 40 and over?
What interventions have been shown to be effective in reducing obesity among non-Hispanic, Black/African American adults ages 40 and over?
How does the prevalence of co-morbidities (e.g., diabetes, hypertension, coronary artery disease, colon cancer) among non-Hispanic, Black/African American adults ages 40 and over who are obese compare with prevalence among members of the same population whose weight is within the healthy/ normal range?
Example 2: Health Determinant Query
What is the effect of physical activity without respect to a population?
Do physical activity levels vary across population groups?
What are the effects of low levels of physical activity on obesity and diabetes?
The Relational Data Model
The relational data model will be a critical factor in configuring the Healthy People 2020 data base that will serve as the target for queries. At present, the information offered here describes a conceptual model that will be used to structure queries. Work by Christopher Murray, et al. (2003) is very useful in this regard. They have defined a multivariable model of proximal and distal causes of particular health outcomes that can be adapted to help organize information within the Healthy People 2020 online database. Once more information about the needs of specific user groups has been gathered, the specific issues addressed through the relational data model can be based on these insights.
Figure 1. Potential Model for Organizing Information within Healthy People 2020
Adapted from Murray et al, 2003
Federal staff preparing data for Healthy People 2020 should define the appropriate variables and linkages for their health topics of interest. It is also clear that the same variables will emerge across different health topics. When programmed and tagged appropriately, these linkages and overlaps will define the web of relationships around any particular health topic.
Below, we have shown a second adaptation from Murray, et al., that provides such a set of linkages for risk factors/determinants, interventions, and outcomes related to chronic heart disease (CHD).
Figure 2. Web of Risk Factors/Determinants, Interventions, and Outcomes, CHD
How the Relational Data Model Fits with the Action Model for Healthy People 2020
The Model to Achieve Healthy People 2020 Overarching Goals (see Figure 3) presents a “big-picture” perspective on how a feedback loop of intervention, assessment, and dissemination would enable achievement of Healthy People overarching goals. It illustrates how interventions, i.e., policies, programs, and information, can impact the determinants of health at multiple levels (e.g., individual, social, family and community; living and working conditions) to improve health outcomes. Results of such interventions are demonstrated through assessment, monitoring, and evaluation.
The Relational Data Model shows how key elements of the action model, i.e., interventions, determinants of health, and outcomes, can be applied to the task at hand—organizing data elements within the Healthy People 2020 Database. It is meant to show how the concepts in the Action Model can be translated into specific relationships and linkages within the database. The end result should be that user queries will yield a comprehensive set of objectives and interventions, reflecting both “upstream” determinants and “downstream” health outcomes.
Figure 3. Action Model to Achieve Healthy People 2020 Overarching Goals
Conclusion
The Subcommittee concludes that the approach outlined above will produce a versatile online resource for Healthy People 2020. Once approved by the Advisory Committee, we recommend that the FIW be engaged to translate this conceptual approach into an operational model for Healthy People 2020 going forward.
References
Christopher JL Murray, Majid Ezzati, Alan D Lopez, Anthony Rodgers and Stephen Vander Hoorn. Comparative quantification of health risks: Conceptual framework and methodological issues. Population Health Metrics 2003, 1:1. Accessible online at: http://www.pophealthmetrics.com/content/1/1/1
Enhancing the Action Model for Achieving Healthy People and Healthy Campus 2020 Overarching Goals
These suggestions would make it more action oriented, inclusive of planning steps and significant numbers of population segments.
Consider the Action Model a planning model that includes action steps such as those in the PRECEDE-PROCEED model and social marketing approach (Theory at a Glance, p 36, www.cancer.gov/PDF/481f5d53-63df-41bc-bfaf-5aa48ee1da4d/TAAG3.pdf). Provide users with “action” steps with action oriented words for program development. These include: learn about needs, describe health problem, audience and program strategy, interventions, plan to monitor and evaluate, implement, disseminate, assess effectiveness, refine program.
For Interventions use “Health communication” rather than “Information.” Health communication encompasses the study and use of communication strategies to inform and influence individual and community decisions that enhance health” (Healthy People 2010, Focus Area 11 - Health Communication, www.healthypeople.gov/document/HTML/Volume1/11HealthCom.htm
To insure that interventions developed are cost-effective use and describe evidence-based explanations. Use words that reflect business approaches such as return on investment (ROI) and public health such as evidence-based, evidence-informed (used to describe recommendations for the new government physical activity guidelines,
The model should describe objectives using the SMART guidelines. An example of this is from the Public Health Information Network (www.cdc.gov/phin/communities/resourcekit/tools/evaluate/smart_objectives.html).
Add “learning” to circled text “Living [, learning] and working conditions.” There are now 75,000,000 secondary and post-secondary education students in US.
Elementary and Secondary Education
In fall 2008, a record 49.8 million students will attend public elementary and secondary schools. Of these, 34.9 million will be in prekindergarten through 8th grade and 14.9 million in grades 9 through 12.
An additional 6.2 million students are expected to attend private schools this fall.
Colleges and University Education
About 18.3 million students will attend the nation’s 2-year and 4-year colleges and universities, an increase of about 3.0 million since fall 2000. College enrollment is expected to continue increasing, reaching a projected 20.4 million in fall 2016.
http://nces.ed.gov/fastfacts/display.asp?id=372
Recommendations from minor to more significant
,
Attachment A. Audience Matrix.
Audience Type / Audience/ User Group / What Should they Know about Healthy People 2020?Primary Audiences
Seekers of Information about Healthy People 2020 / Federal agencies / § Relevance of HP to their audiences (mediated communication)
§ Uses of HP for planning, program management, development, evaluation
State and Local health departments / § Relevance of HP to their audiences (mediated communication)
§ Uses of HP for planning, program management, development, evaluation
Professional associations, societies / § Relevance of HP to their audiences (mediated communication)
§ Uses of HP for planning, program management, development, evaluation
Advocacy organizations / § Relevance of HP to their audiences (mediated communication)
§ Uses of HP for planning, program management, development, evaluation
Philanthropies / § Relevance of HP to their audiences (mediated communication)
§ Uses of HP for planning, program management, development, evaluation
Academics, research and development / § Why and how they should share Healthy People with their students
§ How to align research with HP objectives
§ Why translational and applied research (esp. community-based participatory) are important to achieving and monitoring HP objectives
Secondary Audiences
Targets for Information about Healthy People 2020 / Policy Organizations/ Entities / § Relevance of HP to health and health care literacy
§ Why HP should be on the legislative agenda
State and local elected officials / § How HP can help identify the most important policy changes for improving health and reducing disease and injury burden in your area
§ How health indicators in your area compare with others
Faith-based organizations / § Why HP is relevant to your organization’s members
§ How members can be more informed of issues within HP
§ How organizations can get involved with HP
General public, community based organizations, voluntary organizations, those familiar with community needs / § How HP can offer guidance for personal decisions (being informed of risk factors, diseases and conditions, being able to answer the question, “What can I do?”)
§ How to become involved with HP
Business/private sector / § How HP can offer guidance for promoting worksite health
§ How to become involved with HP
Health care (industry, community health centers, professionals, workers) / § Relevance of HP to their audiences (mediated communication)
§ Uses of HP for planning, program management, development, evaluation
Attachment B
Attachment C