By APHL via LAB MATTERS

1. ASSOCIATION OF PUBLIC HEALTH LABORATORIES
Winter 2020 Issue 1
Inside:
6 Restoring Core Public Health
Services to Ensure Public Safety
16 Spanning Borders for a Cohesive
Public Health Approach
24 The Impact of Bioinformaticians in
Newborn Screening Systems
UnsustainableThe Rise and Fall
of Public Health
Funding

2. LAB MATTERS Winter 202022 APHL.org@APHLPublicHealthLabs
When the APHL Informatics Messaging
Service (AIMS) platform was created in
2008, it was designed to help public health
laboratories send seasonal influenza data
to the US Centers for Disease Control and
Prevention (CDC) to inform surveillance.
“Over the years, AIMS has grown to
be quite a bit more than that,” said
Dari Shirazi, APHL’s manager of health
information technology. “Now not only
do we send messages from one place
to the other, but we also house a lot of
capabilities on AIMS.”Those include
communication portals, electronic
reporting, data validation and even
analysis of whole genome sequencing
data.
These changes have been possible
because of cloud computing, Shirazi
said. The cloud provides access to
shared computing resources in remote
data centers via the Internet, allowing
organizations to tap into data storage
and processing power on demand and
pay just for what they need, when they
need it. “The cloud strategy is all about
trying to use your resources as efficiently
as possible,” he said. For AIMS, turning
to cloud-based services is helping the
platform redefine the roles of public
health laboratories, agencies and APHL in
health data exchange.
Cloud Benefits
Cloud computing can give even relatively
small organizations access to powerful
computing resources without needing
to maintain costly facilities, said Marty
Sibley, MS, a cloud computing specialist
for APHL. The cloud frees a local team
from needing to acquire, maintain and
update servers, and makes it possible to
shift usage up—and, importantly, down—
as demand changes. “You can scale your
organization rapidly with a low cost of
entry,” Sibley said.
Moving AIMS to the cloud in 2014 also
simplified many aspects of security and
maintaining HIPAA and FISMA Moderate
compliance. Data center physical and
environmental controls, for example, are
all managed by the cloud service provider
rather than APHL.
The AIMS team also credits cloud
computing with lowering barriers to
innovation and allowing laboratories
to be more agile when adapting to new
needs. As more public health laboratories
perform next-generation sequencing, for
example, they must grapple with larger
quantities of data. “Using cloud resources,
you can add 1,000 computers to help you
analyze this data very quickly,” Shirazi
said. “Yes, you could buy 1,000 computers
locally and spin them up—but it would
take a lot of resources.”
Bridging Public and Private Sectors
AIMS is now using cloud resources to
expand the traditional boundaries of
public health data exchange. In 2017,
APHL began a private-public collaboration
with Quest Diagnostics and CDC to
establish an approach to validate and
route the company’s electronic laboratory
results (ELR) via the AIMS platform to the
appropriate public health agencies. By late
2019, 91 percent of the 55 public health
agencies were able to receive secure
electronic reportable disease messages
from Quest.
“That particular project was a big turning
point, and it would have been nearly
impossible without cloud computing,”
said Eduardo Gonzalez Loumiet, MBA,
PMP, CPHIMS, CEO of Ruvos, the firm that
INFORMATICS
Moving to the Cloud Signals a Bright Future
for Public Health Data Exchange
By Jill Sakai, PhD, writer
Someday all 5,500-plus private hospitals and clinics in the US will be
connected to public health agencies via the AIMS platform

3. Winter 2020 LAB MATTERS 23APHL.org@APHLPublicHealthLabs
helps develop and implement the AIMS
platform.
Through this project, the APHL and
Ruvos teams learned how to work with
protected health information from a
private-sector company and built stronger
connections with the public health
agencies, setting the stage for new kinds
of AIMS initiatives. They are now working
with private hospitals and clinics to use
the platform for electronic case reporting
(eCR) to public health agencies. When
a healthcare provider adds relevant
information to an electronic health record
(EHR), the EHR will generate and send an
electronic Initial Case Report (eICR) to
AIMS. There, a decision support tool called
the Reportable Conditions Knowledge
Management System (RCKMS) evaluates
the eICR for issues such as reportable
diseases and shares them with the
relevant public health agencies.
“Right now, a lot of doctors have to write
things on various paper forms and send
them into a health department. eICR
is all about collecting that information
electronically without the physician
having to do it,” explained Shirazi. EHR
systems have the capability to create and
send reports. “But if every hospital wanted
to do it alone, they would have to connect
to every public health agency. AIMS is able
to help with that. This is a huge project
that is going to have a large impact on
public health.”
With a few hospitals now in production
and a handful more in the onboarding
process, Loumiet’s team is working with
APHL on efficient ways to scale up eCR.
Ideally, he said, someday all 5,500-plus
private hospitals and clinics in the US will
be connected to public health agencies via
the AIMS platform.
Eliminating the Middleman
These types of efforts by APHL to
standardize and automate reporting can
be a boon for public health agencies,
said Keith Higginbotham, information
technology systems manager of the
Alabama Department of Public Health.
“More electronic interchanges typically
result in data that are more accurate,
more complete and more timely,” he said.
Higginbotham and his team maintain
multiple electronic test orders and
results (ETOR) interfaces for different
customers in Alabama. “Everyone does it
just a little bit differently,” he said, so each
customer’s interface and each electronic
medical record (EMR) vendor requires
extra work to customize the order and
result messages. If APHL could work with
EMR vendors to develop a standard ETOR
interface within AIMS, “that would take a
lot of work off of my staff.”
Loumiet believes that facilitating these
connections—with as much automation
as possible and little hands-on
involvement from the AIMS staff—is the
future of cloud-enabled public health data
exchange. He envisions a streamlined
experience for users, where “with a few
clicks, you’ll be able to exchange data
with anyone else on the AIMS platform,”
he said. “The AIMS team will focus on the
security, making sure the numbers are
being reported to the appropriate people.
But two states will be able to collaborate
with little or no effort from us.”
The AIMS staff are also working on new
applications to help the exchange of ELR
messages between states and even among
multiple users within a single jurisdiction.
Looking Ahead
With so many new capabilities on the
horizon, it’s critical to ensure that labs
and agencies are able to benefit from
cloud-based services.
“I would say five years ago, state agencies
were very against cloud platforms,”
said Higginbotham, who was a member
and past chair of the APHL Informatics
Committee. “Utilizing a vendor that has
their product in the cloud means the
data is essentially outside your personal
control, so there was a lot of fear.”
Policy decisions broadly imposed on
agencies by state information technology
offices may limit labs’ abilities to
leverage cloud-based products. For
example, Higginbotham has been eyeing
a cloud-based laboratory information
management system that looks promising
but is not currently an option for them.
But he has seen greater acceptance over
time as the uses and benefits of cloud-
based initiatives—including those on
AIMS—become clearer, he said. “State
agencies have started to realize it’s not
as scary as they originally thought, and
it seems like more and more states are
moving to cloud-based technology,”
Higginbotham said.
The flexibility of server capacity on the
cloud, while advantageous, also brings
additional responsibilities. Changing
use patterns can complicate planning
and budgeting, Loumiet said. What’s
more, the ease of tapping into seemingly
unlimited computing resources can
sidestep important questions about
whether a planned activity is necessary or
appropriate.
“The argument is cloud computing is
cheaper—and it can be. But it takes
effort, it takes work and monitoring to
make sure that you leverage the services
appropriately,” said Loumiet.
Those efforts also extend to considering
a “reusability factor” when the AIMS
team designs new capabilities, Loumiet
said. Building on recently expanded
connections through AIMS, the team
is looking beyond the US. The first
international trading partner, a laboratory
in Chile, connected with the AIMS
platform in fall 2019 and will be able to
send influenza data to CDC, which can
be useful when planning for the next
flu season in the US. Although such a
connection might have been possible
without cloud computing, Loumiet says,
it happened much more quickly and with
fewer meetings and less equipment by
using the cloud.
“We’re one airplane flight away from a
disease entering the US,” Loumiet says.
“Thanks to cloud computing, we now have
the beginning of an international data
exchange.”n
INFORMATICS
We’re one airplane flight
away from a disease entering the
US. Thanks to cloud computing,
we now have the beginning of an
international data exchange.”
Eduardo Gonzalez Loumiet