How Colorado Prioritizes Public Health Data Modernization

Herlihy: Alicia and I had an interest in HIV early in our careers, which is probably pretty common for people around our age because of the timing of the HIV epidemic. I was really interested in that, sort of, human rights intersection with math and science.

I've been with CDPHE for 14 years now, and being our state epidemiologist really is my dream job. I feel very fortunate to have landed in Colorado and to have the opportunity to -work at CDPHE, where there's high quality public health work happening—especially our communicable disease work.

Cronquist: I'm a native New Yorker, and I was working in New York City as a nurse in the 1990s, so HIV/AIDS was a huge part of what I did. Eventually, I joined the CDC's Epidemic Intelligence Service and went to Colorado for my two-year fellowship.

I learned that the state health department is the level of public health where I am happiest, because it's a great intersection between the federal agencies and our very strong local public health agencies.

Herlihy: That’s a great point. Here, you can specialize but also still have quite a bit of variety in the work that you do. So we do communicable disease epidemiology, but we often get to work on multiple pathogens, do a little bit of field work, and more complex analysis work. It's kind of the sweet spot, I think, in public health, at least for us.

Herlihy: Communicable disease reporting is the mandatory process through which laboratories, health care providers, and others in the state tell public health departments about diseases and outbreaks that are happening. That can be anything from cases of West Nile virus to salmonella to measles. It can also include noninfectious diseases, like cases of lead poisoning.

That reporting is the mechanism that helps us know when more cases of a disease are occurring than is usual, which signals that there’s something we need to investigate. It’s also one way that we discover cases of rare or novel diseases in our communities.

Herlihy: The information we get from communicable disease reporting ultimately helps us implement disease control interventions. Those interventions can look like a lot of different things: for foodborne illnesses, we may need to make sure that an ill food worker is not handling food for a certain period of time or ensure that certain food items are not served at restaurants or available in grocery stores. If we detect cases of certain bacterial or viral infections, we may recommend a person’s contacts receive preventive treatment with antibiotics or vaccination.

Sometimes the intervention is simply getting a message to the public that something unusual is happening so that they can protect themselves and their families.

Herlihy: The COVID-19 pandemic was humbling and quickly taught us that our aging systems and manual reporting processes were insufficient for the volume of data that was coming our way. As soon as we had a chance to finally look up from the pandemic and take a breath, we implemented a new surveillance system to help us collect, analyze, and interpret health data.

Cronquist: The focus of a lot of the changes has to do with electronic reporting methods, and there's really two big flavors of that. Electronic lab reporting has been around for a decade, and I think we're now getting to the point where most laboratories report most things electronically.

In contrast, electronic case reporting (eCR) is increasing very quickly. During the year that we've been working on this project, it has progressed faster than we expected. In this iteration of the rules, we started to address what the rapid growth of eCR means for traditional disease reporting. That's probably an area where we'll need to make some modifications down the road.

Cronquist: The goal is to detect and respond to communicable disease quickly to minimize its impact on Coloradoans. To do that, we're strongly encouraging providers, laboratories, and other disease reporters to send us routine data electronically rather than by fax or phone, which saves disease reporters time, reduces errors, and allows us to take action faster.

We’re also clarifying reporting roles. We hope we're going to reduce some of the duplicate reporting that happens now because of lack of clarity around who is supposed to report what and when. There used to be several conditions for which both laboratories and providers were responsible to report—so that’s two reports for one case. We’re removing 18 conditions that providers need to report and clarifying that only labs need to report these conditions moving forward.

Herlihy: We automated several of our processes and linked different systems to improve data quality. For example, we linked our immunization registry to the surveillance system, which provides us with important information on immunization history, which is especially important in cases of vaccine-preventable diseases. It also improved the completeness of our race and ethnicity data, because that data in our immunization registry is much better than what we typically get from case reports.

Herlihy: A lot of what we are trying to understand in communicable disease control is who is at risk and who might be some of our underserved or particularly vulnerable populations. Understanding where we see disparities and trying to address those disparities is fundamental to a lot of public health work. So race and ethnicity data certainly helps us understand some of the gaps that we need to fill.

Cronquist: We know it can be difficult for labs to collect that information. We're trying to be realistic, and this fills a gap when information is missing. We still absolutely want the labs to report everything that they need to report to us, including race and ethnicity. We're just taking a multiprong approach to get that information.

Cronquist: It's been humbling. We knew that our rules had not been fully revised for a couple decades, so we were overdue. The thing that stuck out to me the most is just how confusing our prior rules were to everyone who tried to read them.

It has been heartening to see how invested our data reporters are in doing the right thing and in making sure CDPHE has the information we need. They were really appreciative of our engagement with them and asking for their opinions as part of the process for making these updates. The feedback we got on the proposed changes was overwhelmingly positive.

Herlihy: We are worried about the future of funding for public health and the reality that we might need to do more with less. It's helpful to have done some work now to increase our efficiency. Receiving more and better data upfront results in less manual effort by our staff. If we find ourselves in a fiscally constrained environment in the next few years, the efficiency we've built in will be critically important.

Cronquist: Engaging with our stakeholders and the people who do the reporting has been very valuable. It has taken us a lot of time, but it’s been really worthwhile. They’ve told us what works, what doesn't work, and how we can improve our messaging.

Working with Pew has also been very valuable. Hearing from Pew about the best practices other states have been implementing has really helped support us through this process.

Herlihy: It's very true. Before we started working with Pew, we knew that we needed to update our requirements, but it felt like a monumental task. We were struggling with figuring out how to get started, how to really modernize some of our rules, and what the scope should be. The ability to work with you and take it step by step and have you at our side has been very beneficial to us.