This project is intended for the HEALTH primary area and COMMUNITY NETWORKING as a secondary area.

The Urban Health, Inc. in collaboration with:

• The Harlem Park/Lafayette Square Empowerment Village Center (HP/LS Ctr.),
• Maryland Department of Health and Mental Hygiene, and
• Care Partners

will design, develop and implement an electronic information network (Urban Health-NET). The network will focus on providing health education to the residents of the urban underserved communities; training community health workers (CHW) through a distance leaming (DL) program: tracking health concerns; and generating health data profiles. The network would also give doctors and staff in area hospitals and health centers the connectivity that would ultimately result in an integrated medical record for over 200,000 Medicaid recipients and low-income citizens of Baltimore's Empowerment Zone. One of the major goals of the project is to provide the clinical professionals, serving the most disadvantaged citizens of our community, access to the Internet, E-mail, clinical information systems, library information, patient information and medical research data bases.

Health care providers that serve poor urban residents will now have the capability to enter a multitude of important patient data with total confidentiality, establish computerized reminders for physicians and patients to enhance compliance, and thus improve clinical outcomes. Local community organizations, Baltimore City, and the State of Maryland could use this network to assess community health issues. Public health officials could utilize the network as a single source for many status indicators. A new program entitled, "Closing the Gap," initiated by the Maryland State Department Health and Mental Hygiene recently, is an example of a potential application for this network. The program will attempt to reduce the morbidity and mortality gaps between African-American and Anglo-American residents of the State of Maryland through the use of the Minority Health Information Network This will provide a community network and outreach programs that will focus on:

• Heart Disease
• Infant Mortality
• HIV/AIDS
• Cancer Screening and Management
• Diabetes and Immunizations

in Baltimore City and Baltimore County. Currently, we do not have a central computerized system to track and/or monitor pediatric immunizations or clinical outcomes for any major chronic diseases anywhere in the state. With the Urban Health-NET in place, major health prevention deficits could be detected and monitored. Preventive measures could be initiated. In addition, communities could measure their own health indicators against statewide information. The network will also help the state shape policy, and direct resources in order to more effectively combat acute community health problems.

The Urban Health, Inc., in collaboration with HP/LS Ctr., the Maryland Department of Health and Mental Hygiene and Care Partners MCO, has a unique opportunity to initiate three (3) major goals:

1. provide health education and training for Community Health Workers (CHW) and professionals that utilize Information Technology (IT);
2. improve the dissemination of health care information and enhance access and coordination of care for our community’s most vulnerable and medically underserved populations - indigent children, pregnant women, and poor chronically, ill senior citizens; and
3. ultimately improve the health care information system for the state of Maryland's 400,000 Medicaid recipients.

The problems to be addressed are:

• High unemployment (i.e. 70% in the Harlem Park community of UH, Inc.)
• Lack of health education programs, health care providers/clinics or hospitals for the residents of our service area
• Lack of integration of health care information among health care providers
• Time-consuming delays in obtaining medical records
• Duplication of tests and procedures due to lack of timely patient information
• No access to Internet medical resources
• No E-mail capability among providers
• Lack of up-to-date on-line clinical information databases
• No on-line access to medical research databases

The health and economic problems facing Baltimore, Maryland, are not unique to this region of the nation. The most critical problems are:

• Poor educational systems
• High employment
• High rates of adolescent pregnancy
• Excessive numbers of low birth weight babies, and
• High infant mortality rates.

These tragic realities are followed by a low percentage of EPSDT screenings and low immunization rates. The vast majority of these problems exist among poor Medicaid recipients and the medically indigent. Many health and economic problems facing these citizens relate to a fragmented health care delivery system and a lack of coordinated care. Finally, community-wide networks are social systems that link local residents and organizations, allowing them to communicate, share resources, and participate in efforts to address community needs and build on existing social and cultural capital. In Baltimore, Maryland, the critical needs of low-income residents - typically African-Americans, single parents and senior citizens -include housing, crime prevention, family support and youth development. However, the contribution of community-wide networking to problem-solving is hampered because information regarding needed social and economic services is fragmented. In addition, a sense of isolation and depression burden most of our disadvantaged neighborhoods in Baltimore. The Urban Health-NET offers the potential to support traditional community-wide networks by facilitating more extensive communication and coordination related to problem solving efforts and the delivery of the telecommunication components (staff, hardware, and software) that support health care providers. This effort will enhance and improve the quality of preventive and primary care.

One of the major barriers to improving the health of the nation is the fact that there is no uniform method for determining comprehensive community health status that has been universally accepted and consistently applied. Although there are many sources of information that report various indicators of health status, they tend to be reported intermittently and independently and are often used for some ad hoc purpose. This absence of a widely recognized health status monitoring system, especially on the county and community level, allows health problems and priorities in our communities (and states and nation) to be defined by the managerial objectives of our health institutions and government agencies, rather than by any form of comprehensive, objective appraisal. The Institute of Medicine (IOM) of the National Academy of Sciences, in its influential 1988 report on the Future of Public Health, emphasized that assessment was one of the core functions of public health and recommended that there should be a regular and systematic collection, assemblage, and analysis of information on the health status and needs of communities. More recently, the IOM Committee on Using Performance Monitoring to Improve Community Health outlined a community health improvement process (CHIP) "through which communities can assess health needs and priorities, formulate a health improvement strategy, and use performance indicators as part of a continuing and accountable process." A fundamental requirement for a successful CHIP is the community health profile made up of sociodemographic characteristics, health status and quality of life indicators, health risk factors, health resource indicators, and other measures that can be used to support priority setting, resource allocation decisions, and the evaluation of the impact of health programs. The intent of such a comprehensive profile would be to help the community establish and maintain a broad strategic view of its health status and the various factors that influence it. Selection criteria suggested for the performance indicators that might be used in the community health profile include: established validity and reliability; evidence supporting a link- between the indicators and actions intended to influence it: availability in a timely, manner and at a reasonable cost; and derived from and/or included in other indicator sets already existing.

The United States now spends nearly a trillion dollars annually on health expenditures. Both as a percentage of national productivity and per capita, this amount is larger than any other nation in the world. However, this tremendous expenditure has not secured the U.S. a rank- among the "healthiest" nations. In fact, for many health indicators, such as infant mortality and measles immunizations, the U.S. ranks below some countries characterized as underdeveloped [Starfield I 99 1, World Health Organization 1995 ]. It is noteworthy that the debate on national health care reform has dealt mostly, with insurance coverage and medical care financing, while avoiding any serious discussion concerning the true health of the nation.

A major barrier to any discussion of the nation’s health is that there is no uniform accepted method for determining a community's, a state's, or a nation's health status. Although there are many sources of health data, there are no standard data definitions, formats, or reports across the health care industry. Thus, health care data is widely used (and misused) in an ad-hoc manner to justify managerial objectives of health institutions and agencies, a mass of mandated categorical funding, and a variety of political agendas.

A community health profile is made up of socio-demographic characteristics, health status and quality of life indicators, health risk factors, health resource indicators and other measures that can be used to support priority setting, resource allocation decisions. Therefore, to research health information containing different categories require extensive human resources.

• The current process is labor-intensive and slow. Hundreds of individual sources of data must be identified and contacted. Data are often provided in hard copy formats and must be manually checked, validated, and entered into spreadsheets.

• Longitudinal trend analyses over many years are cost prohibitive for most communities. Since each application is expensive and time-consuming, the capability to fund and produce annual assessments in a single community is limited.

• Most public health funding comes from the State and Federal governments. A statewide health assessment would help to prioritize funding and serve to enable effective program evaluation based on quantifiable outcomes assessment. Since nearly all data elements available in Maryland are available in most other states, there is reason to be confident that Health-Net might be expanded nationally and even internationally.

• With the massive amount of health data involved. many interesting relationships and correlations of health indicators can be found and investigated.

To overcome these limitations, we are building a data warehouse for the UH-NET health care data. This data warehouse will also provide a flexible infrastructure for ad-hoc exploration, data mining, and the customization of community reports. In this proposal, we present an initial indicator design for the data warehouse. Finally, we discuss the challenging problems and opportunities we face as the data warehouse continues to evolve.

Important missions of a data warehouse include the support of decision-making activities and the creation of an infrastructure for ad-hoc exploration of very large collections of data. Decision makers should be able to pursue many of their investigations using browsing tools, without relying on data base programmers to construct queries. The emphasis on empowering users places a premium on an understandable data base schema that provides a natural basis for navigating through the data.

The State of Maryland's Department of Health and Mental Hygiene receives data from 24 local health departments weekly. These provisional weekly data are then further reviewed, edited and analyzed at the local (Baltimore) level and state health departments to produce a yearly summary. This massive amount of information is derived from health care providers and laboratories; some reports come from other sources. This information, just on "notifiable diseases" alone, adds up to more than fifty (50) types of communicable diseases.

All of this information regarding communicable diseases is managed through one (1) division, Community and Public Health. There are five (5) additional divisions that manage other important health-related information. Yet, there is no computerized system of connectivity to retrieve or exchange information on the various diseases or disorders. The Urban Health-NET will help to resolve some of these barriers and facilitate greater access to health information.

None of the six (6) Care Partner (CP) Centers currently have access to computerized patient information from other community health care providers, access to the vast amount of medical information available on the Internet, E-mail services, access to sophisticated computerized clinical information data bases or access to medical research data bases. The computer systems currently in use at the CP Centers are limited to systems designed primarily for billing purposes. Few of the physicians have access to a personal computer at their clinic.

While the University, of Maryland at Baltimore (UMAB) Hospital Information System with its patient information and clinical information databases is widely available within the UMAB hospital facilities with over 600 terminals in use, very few of the UMAB's attending physicians have access in their offices or in the patient care areas. The system is primarily used by the clerical staff, nursing services staff, and to a limited degree, by the resident physicians. Most UMAB physicians have personal computers in their offices and several medical departments have local area networks.

This project will extend the UMAB health information network to the CP Centers and connect all UMAB physicians to the network. The availability of patient medical record information, clinical information databases and medical research databases will allow these physicians, who are dedicated to providing health care to the most disadvantaged of our community, to provide timely care with improved outcomes and at reduced cost. This project seeks to reduce the disparities of access to medical information that is currently encountered by the health care professionals who work in these institutions. Since much of the care provided is uncompensated, these community health care centers are unable to provide the computer equipment, software and training necessary to assist these health care workers in providing the most effective and cost-efficient care.

During this 12 month planning phase, one of the most important elements that we will design and develop is the health status indicator and indicator categories; peer group selection criteria and process; a formal scoring system for rank ordering the indicators; and a system to measure outputs.

Some of the major characteristics that we will initiate are:

1. Health status
2. Health risk factors
3. Health resources indicators
4. Socio-demographics characteristics
5. Cultural and ethnic characteristics
6. Evaluation of the impact of the health programs

During this planning phase, three sub-phases will occur:

1. Research,(3-4 months);
2. Design,(2 months); and
3. Development,(6 months).

A fourth sub-phase (implementation) will take place after the full proposal has been developed and funded for a two-three year period.

During the research phase, a local and nationwide search will be conducted regarding existing programs of this type. Once this phase has been completed, State political and health leaders must be contacted and a marketing plan must be developed and put into action to sell the program to the officials, who must approve the program. However, we have already gained good support from local Community leaders, Academic officials and some State Health Department officials.

Most, if not all of the needed indicators are already in place. Rearranging the indicators on the state mandated forms maybe the most difficult task. Once the design has been approved, development of the entire program will occur rather smoothly.

Implementation will take place after this PLANNING grant has been completed and resubmitted as a completed TIIAP proposal.