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Secretary's Advisory Committee on
National Health Promotion and Disease Prevention Objectives for 2020
Phase II –Recommendations for Implementation of the
Healthy People 2020 Objectives
U.S. Department of Health and Human Services,
Hubert H. Humphrey Building
200 Independence Avenue, SW, Washington, DC
Eighth Meeting: January 7-8, 2009
Day 1: January 7, 2009
I. Introductions and Desired Outcomes of the Meeting
9:00 AM - 9:20 AM
RADM Penelope Slade-Sawyer, Deputy Assistant Secretary for Health
(Disease Prevention and Health Promotion) welcomed the audience members
to the eighth meeting of the Secretary's Advisory Committee on National
Healthy Promotion and Disease Prevention Objectives for 2020. She
reviewed regulations for Federal Advisory Committee (FAC) proceedings
and introduced Dr. Jonathan Fielding, Committee Chair.
Dr. Fielding remarked commented on the poor state of the economy and
the relationship between health and productivity. He suggested the
Committee help the U.S. Department of Health and Human Services (HHS) to
examine how its activities can broadly support economic stimulus through
a balanced portfolio of short-term and the long-term strategies. He
reminded participants of the Committee's charge and said the main
purpose of the meeting would be to more fully develop the Committee's
work plan for Phase II efforts. He noted the following meeting aims:
- Discuss the recent progress of the U.S. Department of Health and
Human Services (HHS) and the Federal Interagency Workgroup (FIW)
regarding the objective development process, the Healthy People
Consortium, state-level activities, and other developments;
- Clarify HHS needs for input FAC input during Phase II of Healthy
People 2020 development;
- Discuss the recent work of the Advisory Committee's two active
subcommittees, which have addressed the topics of User Questions and
Needs; and System Specifications for a Healthy People 2020
interactive, Web-accessible database.
- Hear expert presentations and discuss implications on the
subjects of evidence-based actions, data and trends, and how Healthy
People 2020 can be used to drive accountability
- Flesh out the Committee's work plan for Phase II efforts,
including decisions about how many and which subcommittees are
needed, and the timing and format of future meetings.
Dr. Fielding explained that in Phase II of its efforts, the Committee
would use a different process to submit recommendations to the
Secretary. Rather than providing a single, final report on their work
(as they had done in Phase I), the members will develop a series of
short documents responding to the HHS' immediate needs for feedback. Dr.
Fielding reviewed the vision statement, mission statement, overarching
goals, and action model that the Committee had recommended in its Phase
I report. Noting that it would be critical to engage multiple sectors in
the work of Healthy People 2020, he emphasized that dissemination of the
Committee's recommendations to the Secretary is very important.
II. Update on the Healthy People Development Process
9:20 AM - 9:45 AM
The FIW's Activities and HHS needs for Phase II
RADM Slade-Sawyer explained that the Federal Interagency Workgroup (FIW)
uses feedback from the Committee to develop the official departmental
document that will move forward. Since the Committee's last meeting, the
FIW submitted key elements of Healthy People 2020 for HHS clearance. The
FIW versions of the vision, mission, and overarching goals were nearly
identical to those recommended by the Committee, with some minor
changes. She reviewed and explained these changes to the Committee.
HHS is now starting development of specific objectives, including
baselines and targets. Other Healthy People elements under discussion
include implementation strategies, outreach to the public and federal
partners, and the format of Healthy People 2020 itself (e.g., paper
versus electronic). Another priority is the development of criteria for
selecting knowledge-based implementation resources. There are varying
levels of evidence to support strategies and interventions published in
the literature and shared anecdotally. An HHS recommendation will be
seen as an endorsement, so it must be prudent about which strategies it
puts forth.
HHS has issued guidance for developing objectives to Healthy People
2010 Workgroup Coordinators, who have been asked to convene their
planning workgroups to identify specific objectives that they will
recommend for inclusion in Healthy People 2020. The Guidance document
instructs Workgroup Coordinators to gather the data, science, and
rationale for each proposed objective, to develop consensus among their
stakeholders, and to submit official memoranda on objectives to be
vetted for inclusion. RADM Slade-Sawyer closed by providing a list of
areas in which HHS would appreciate receiving Committee input.
Top Priorities for Committee Feedback to HHS
- Target selection (e.g., ambitious or realistic?
Incorporate knowledge of effective interventions?)
- Healthy People 2020 objectives (e.g., are they
on-track? are key areas being omitted?)
- Topic areas and their organization
- Identifying knowledge-based resources that HHS can
recommend for stakeholder use
- System specifications and cross referencing of the
Healthy People 2020 objectives
Other Issues: Translating, Implementing, and Maintaining
Healthy People 2020
- Translating Healthy People 2020 (including help with dates for
strategic release of materials).
- Types of companion documents to be included.
- Approaches to developing case studies that will be useful to
Healthy People audiences.
- Increasing public engagement in Healthy People 2020
(development, launch, post-launch).
- Ideas for attracting new members to the Healthy People
Consortium.
- Ideas for data mining — finding and sustaining reliable,
population-specific data for the objectives.
- Input on changing/revising, adding, and eliminating objectives
throughout the decade.
- Methods to facilitate the availability of timely and transparent
information for the public.
Technical Assistance
- Types of technical assistance needed for Healthy People 2020
users.
- How and when technical assistance should be provided.
- How to provide training tools that are specific, but encourage
creativity and flexibility.
III. Needs of Specific Target Audiences
9:45 AM - 10:15 AM
Findings from user focus groups
Dr. Douglas Evans, Chair of the Subcommittee on User Questions and
Needs, said that feedback is needed from potential users of Healthy
People. The list of potential audiences in the Phase I report was used
to develop a feasible audience research plan. Members coordinated focus
groups, informal discussions, and key informant interviews to examine:
potential users' familiarity with and use of Healthy People;
informational needs that could be addressed through Healthy People 2020;
and ways to increase use—especially through electronic media. Eva Moya
detailed the findings of three focus groups conducted at the University
of Texas at El Paso (UTEP) involving: 1) academicians/scholars; 2)
community-based organizations/agencies; and 3) students—undergraduate,
graduate, and doctoral—from a variety of disciplines. Main findings
were:
- Academicians and scholars highlighted the need to connect other
prominent health-related Websites to Healthy People 2020. They felt
that Healthy People should serve as a clearinghouse.
- Community organization asked for guidelines to improve data
collection and reduce reporting errors. They wanted information
about available funding and resources. Tracking data and progress
reviews would help to tailor programs and, change directions. Local
data should be offered in real-time.
- Students saw Healthy People as a tool for decision-makers, not
communities. To be user-friendly, Healthy People must be culturally
and linguistically appropriate, easy to use, fun, meaningful, and
visually engaging. It should offer case studies and documents for
download, and highlight areas for research. It should be life-course
oriented with an early focus on students.
How the proposed database can meet the needs of diverse Healthy
People users
Ensuing discussion among Committee members touched on the following
issues: focus group members' desire to get involved; the need to tap
into enthusiasm through mechanisms, such as the Healthy People
Community; infrequent use of Healthy People as an accountability device;
persuading secondary audiences that they have a role in health;
opportunities to use Healthy People in schools. Dr. Fielding said these
results show there is a hunger for this information, but people don't
know how to use it. It might be useful to examine which audiences (or
"action groups") could help to reach each overarching goal.
IV. Expert Presentation: Data and Trends
10:30 AM - 11:15 AM
Dr. Edward Sondik, Director of the National Center for Health
Statistics, spoke about the quality and availability of national data,
target setting methodologies, and challenges to measuring health equity.
He noted that disparities are easier to measure than equity. Health
equity and health disparities deal with portions of the population—not
the entire population. To monitor progress for Healthy People, the data
must: be representative, support population-specific analyses, and
include supporting variables.
The "minimum template," which drives data collection, shows the level of
detail used to portray progress toward the objectives. Only a fraction
of the objectives have enough data to complete the template, which is
why the detailed Healthy People data tables show numerous "DNCs," (i.e.,
"did not collect").
Quality of Data. Dr. Sondik praised the management
control element of the Healthy People 2020 Action Model and said that
feedback has not been strong enough in past iterations. While NCHS sends
analyzed data back to the HHS agencies, there is no information
available to manage progress toward targets. Current data don't contain
intermediate variables (process variables that would offer clues
regarding progress toward the targets). The workgroups for each of the
Focus Areas look at interventions, evidence, and outcomes instead of
intermediate outcomes. Healthy People midcourse reviews include a
synopsis of current progress toward the Healthy People objectives, but
they don't offer insight into factors influencing progress toward the
targets. The data simply reveal whether or not the targets have been
achieved. Dr. Sondik viewed this as problematic and recommended changes
in information strategies used for Healthy People, as summarized below:
- Sustained resources for survey activities are needed to provide
contextual information and long-range planning. Surveys cannot be
developed, fielded, and analyzed in short order. Healthy People is a
10-year effort, however, the federal budgets are annual.
- It is important to be able to link national data sources to
state, regional, and local data that have been collected using the
same standards.
- The National Health Interview Survey should collect data on
indicators in Healthy People 2020.
- Economic data—including program costs and population income
groups—should be incorporated.
- Collaboration across the department (not simply coordination) is
needed to leverage data that is collected by all agencies (e.g., the
CDC, SAMHSA).
- Quality standards are critical. The value of the NHANES, NIHS, and
SAMHSA surveys is that all of those surveys meet OMB standards.
- Measures of functioning have not been adequately emphasized.
- There is great potential for electronic medical records to affect
data collection for Healthy People.
Target-setting Methodologies. Dr. Sondik said that
objectives need targets to drive action. He posed questions that can be
considered in developing targets, such as: What is the trend? What could
one achieve if one changed risk behaviors? Should models be used to look
at trends? Should a target be aspirational, or achievable? How can an
emphasis be placed on translating research to practice, and how would
one track that? Should there be one target for the entire population, or
several targets? If we see a positive trend, should we set a target that
is on the trend, or beyond it? If we choose aspirational targets, how do
we relate our progress 3 or 4 years in the future to that target? Dr.
Sondik noted that for Healthy People 2010, a decision was made to use a
single target for multiple populations as a way to address health
disparities. The target setting method referred to as "better than best"
(whereby the target for the racial and ethnic populations for a given
population-based objective was set at the same 2010 target and set at a
target better than the best racial and ethnic population for that
objective) was used for almost half of the objectives. However, the
rationale and methodology for target-setting was not consistent across
different areas. Groups should receive guidance on how to do this.
Measurement of Health Equity. Dr. Sondik argued that
equity is about equal resources, not outcomes; equity is achieved when
equal resources are applied. The current strategy for measuring
disparities is to identify the best outcome among population groups and
then to analyze the difference between the best result and the other
results. However, this analysis is difficult to convey in a
user-friendly way. To measure health disparities or health equity, data
for specific population groups is needed, which requires adequate sample
sizes. This is a budget issue.
V. Expert Presentation: Evidence-Based Actions
11:15 AM - 12:30 PM
Dr. Shawna Mercer, Director of the Community Guide to Preventive
Services, offered insight into her experiences in compiling
evidence-based guidelines. The Community Guide presents systematic
reviews of all available evidence on the effectiveness of
population-based and health-system-based interventions in public health.
The reviews are formulated by a non-federal, independent, and rotating
Committee appointed by the CDC Director (the Task Force on Community
Preventive Services). This team of researchers, public health
practitioners, and health and representatives of professional
organizations offers concise recommendations focused on population-level
interventions in the U.S. It complements the Clinical Guide.
Dr. Mercer provided a brief history of the Community Guide and the
rationale for its creation in 1996. To date, the Task Force has
developed 210 recommendations in various categories. Challenges include
the complexities of putting evidence into practice; providing
information about cost; and engaging practitioners in conducting and
disseminating the reviews. Participation and collaboration are essential
if recommendations are to be used. Many options for intervention have
been identified in some topic areas, while none have been identified in
other areas. Criteria used to prioritize health topics are overall
attributable burden, preventability, leverage, and ability to address a
reasonable portion of the topic. The Task Force has developed a list of
25 high priority areas, with others ranked as medium or low priorities.
Within each prioritized topic, they also prioritize interventions for
review. Dr. Mercer elaborated on these processes.
The Committee members took a break for
lunch, returning at 1:15 PM
VI. Identifying Best Available Knowledge and Evidence
1:15 PM - 2:30 PM
Range of evidence for specific interventions to be recommended for the
Healthy People objectives
Dr. Fielding opened discussion by asking for short-term recommendations
regarding the use of evidence as a basis for recommending interventions
for achieving Healthy People 2020 targets. He also asked how evidence
should be used to affect target-setting and data collection, as well as
feedback mechanisms. He suggested the Committee provide guidance to the
Secretary on these issues within a relatively short period of time, as
the objective and target-setting processes are now underway.
A Committee member noted that comparative effectiveness, not just
effectiveness, would be important in the future; he asked how the work
of the Community Guide could be framed in that way. How should the
comparative effectiveness models in that system be used for economic
recovery? Dr. Fielding said the Community Guide looks at costs, but this
information is rarely available. Even when there is cost information,
comparing levels of effectiveness with dollar investments is seldom
possible. He suggested there might be opportunity to recommend that the
Secretary focus on return on investment, both with respect to improving
health and increasing productivity.
A Committee member noted that, both in communities and in academia,
people lack basic templates for cost analysis. Economists have different
understandings of how to do cost-effectiveness analyses. Perhaps a tool
could be offered to help people collect information about costs in
community and research settings. Another member responded that there are
questions in economics about measurement and how to advance it. The Gold
Report offers guidance on some controversial issues. He cautioned that
there are not many people who are well-trained to do this, and there
aren't many places to get trained. It is also important to consider the
scale of the benefit. That is, if an intervention is cost-effective
that's good, but if it doesn't affect many people, it is not as
important to implement as a less cost-effective intervention that might
affect more people. This brings up the concept of "net health benefit."
The first Committee member rejoined that she was suggesting the need
for "cost-effectiveness for dummies" (i.e., a way to do basic cost
analysis that would be accessible to more people). A third member asked
why such a tool is needed. Would the idea be that, since cost data are
not being collected, there would be more cost data if it was easier for
people to gather? A member with training in economics said such data
would be in the hands of people who are untrained. Doing a job "80
percent right" isn't useful. Dr. Fielding agreed that while
cost-effectiveness analysis is a simple task, cost-effectiveness is
important factor and consideration. People should be encouraged to pair
with someone who has the expertise to do it effectively.
Another member said that he and his colleagues input cost information
for about 400 interventions that they had examined in Wisconsin. It was
challenging because information varied depending on whose costs one was
talking about. In the end, they decided that their analysis was complete
for public release. Returning to her initial point, the first Committee
member explained that she was arguing for more simple ratings, such as
looking at categories of "lower cost, higher cost" to give people a
sense of relativity without scaring them.
Guidelines for identifying and selecting interventions
Patrick Remington directed the members' attention to an unpublished
report that he and his colleagues produced in Wisconsin. He commented
that the linkages between the Community Guide and Healthy People are
evident in usage of common terms, like "topic areas." There should be an
obvious link to the Community Guide. It should be possible for users to
go right from the Healthy People topics to an evidence-based source. The
Guide is not sufficient because there are a lot of things that people
are doing at the community level that aren't addressed. For Healthy
People 2020, users will want access to more information than just
systematic reviews. Themes of the ensuing discussion are summarized
below.
Finding Balance between Top-down and Bottom-up Approaches.
Communities may view evidence-based approaches as "top-down" solutions.
Community members want to see their own work, passions, and needs
reflected. Thus, two perspectives should be considered: 1) where can I
get the best return on investment? (top-down) and 2) I have a passion
for this; where is my perspective incorporated? (Bottom-up.)
Guiding Users in the Absence of evidence. If there is
no intervention with the highest level of evidence, should users be
directed to an intervention with a lower level of evidence, or should
another intervention be identified that will show the strongest
evidence? One should look hard for highly effective interventions before
moving on to those with more mixed evidence. While it is important for
evidence to drive the process, for some high attribution problems, the
evidence does not exist.
Helping On-line Communities to Generate Data. Might it
be possible to create virtual communities that can generate the evidence
through Web-based tools? If one doesn't have a research project to
generate evidence, one could design methods and develop instruments for
use by others. Those protocols could be used to enlist communities to
participate in an online process to generate the evidence-base. For
example, the Eastern Clinical Oncology Group allows institutions to
enroll patients in clinical trials through an online system.
For example, one could reach out to various communities of color or
different cultural groups to try to enroll them in something like a
"clinical trial unit" for interventions to address disparities. This
information could be put into a learning community or a wiki, enabling
use of a knowledge-management system. However, such networks can start
to serve their own purposes. It takes thoughtful leadership and courage
to randomize people in and then randomize them out, in order to ensure
that such an approach would be a real experiment.
Academicians often struggle with a lack of community-based, relevant
pilot data that they can then take to the NIH to fund more rigorous
studies. The idea of the Healthy People Communities could encourage
people from the community to think about what they need to collect and
how to enter it. Academics could then use some of that as pilot data to
do the more rigorous trials or experiments.
Addressing the Lack of Primary Evidence. There are
larger issues of a lack of primary evidence. One must ask, "Who is
generating evidence that we have to use?" Is it NIH? If a foundation
decides to fund studies that are designed to achieve a specific goal, we
are lucky. There isn't really a mechanism for generating evidence for
public health. There is a need to close the gap between the things that
people are doing all the time, while academics are saying, "There's no
evidence."
Encouraging Coordination and Funding for Research. The
Community Guide clearly identifies the research gaps, but there's no
single federal agency to take those on. There should coordination to
ensure that priority opportunities for research are addressed where
there is real potential for benefit, but resources are lacking. Also,
the concept of generating new knowledge does not extend far enough.
Replication is needed. There is a need to get evidence for interventions
that may be dull from a discovery point of view (i.e., research need not
be novel every single time. Practice-based evidence is not just about
building systems for clinical trials, but building systems that are
ready for natural experiments, such as surveillance systems.
There has never been a significant pot of money for population-based
research with clear priorities. Unless that exists, it will be difficult
for Healthy People to get where it needs to go. There is a role for NIH,
but there must also be a central place within the federal government
that has as its mission public health or population-based research.
Additional issues raised in this discussion included:
- The importance of collecting data on policies. If we're going to
focus on determinants of health, we need to start identifying data
on determinants of health.
- The Pan American Health Organization (PAHO) as a resource. It
has an evidence-based network for health policy issues that might be
useful.
- The need to combine databases on economic, physical,
environmental factors that influence health. Geo-coding can be used
to link economic, social, and environmental data to health outcomes.
- The possibility of having a virtual Healthy People 2020 serve as
a one-stop hub for the information related to all the different
parts of the model.
- Resources, including funding and staff, needed to build and
maintain such a system.
Dr. Fielding distributed a preliminary draft of short-term
recommendations for the Secretary. He noted that the recommendations
could be embellished so that there would be a paragraph for each one. He
reviewed the list with members and asked them to improve it for
discussion later in the meeting.
VII. Data and Trend Issues
2:30 PM - 3:00 PM
Target-setting methodologies
Dr. Fielding led the discussion regarding the use of evidence to set
targets. What does it mean to have data-based objectives? How should
trend information be used? In the absence of specific evidence, should
one assume that trends will continue, or that underlying factors are
changing? How should quantitative tools be used to set objectives and
targets?
A member argued that in target-setting, one should consider where one
will be if all factors remain the same. Trend data is needed to project
the trajectory of the data 10 years into the future. This permits
decisions about whether it's realistic to hold the course, to increase
the rate of improvement, or to lose ground. Where will things be if
changes are achieved? Rather than using a "better than best" target
setting method, it may be more useful to ask, "Compared to where I think
we'd be normally, where would I like to be?"
Dr. Fielding expressed reservations about this idea, offering examples
of obesity and smoking in California. A few years ago, one would have
thought the rates of smoking would continue declining and would be lower
by now. However, the trend is flat. There is a hazard in relying on the
trend data to make predictions. One can use expert opinion instead, but
then achievement of the target is unrelated to the intervention. A
member asked if targets should reflect an outcome, a process change, or
both. Dr. Fielding said evidence-based interventions can be viewed as
proxies for outcomes. Other themes of the discussion are summarized
below.
Planning for Changes in Knowledge and Tools. An
intervention that is the "best" right now may not be best once
technologies change. It may be necessary to set targets that are not
simply one target set 10 years from now, but a series of intermediate
goals. If we set a single target 10 years into the future, we miss the
opportunity to take advantage of new knowledge and technology, and to
benchmark current data against economic recovery.
Defining Success and Failure. What are the implications
of how Healthy People objectives are set? For Coca-cola, the
implications are shareholder value, executive bonuses, and financial
incentives that impact the organization. In public health, what are the
implications if an objective is not achieved? Success and failure can't
be measured on the basis of whether or not an objective has been met,
because there are mitigating factors in how the objective is set
initially, and whether or not progress occurs. An indicator of success
could be the change in investment (e.g., in a program, or in efforts to
change policy related to a particular objective).
Limiting the Focus. It is not possible to focus on
everything. Standardized modeling based on demographic trends and
subpopulations could be used to create tables for the objectives, and
then a subset of those could be chosen based on evidence of community or
clinical efficacy. Those objectives could be ranked as having "stretch"
targets (i.e., implementing a greater portion of the effective,
evidence-based tools at our disposal). Metrics are needed for a limited
number of priorities. At the end of the decade, there should be 50
priorities with a trend line that demonstrates improvement. This would
essentially do the work of prioritization.
Stratifying Objectives. Should emphasis be placed on
objectives that have enough data to permit detailed examination and the
setting of measurable, intermediate benchmarks/targets? Other objectives
could be on a second tier. They would address issues of interest, but
lack clear evidence about how to reduce overall burden; thus, less time
would be spent on them. For interventions where there are
community-based or clinical interventions that have been demonstrated to
be effective and efficient, stretch targets should be set. There could
be iterative consideration of whether targets should focus on outcomes
or on the interventions.
Examining the Value of Projections. What is the value
of projecting what the trends will be? One could project trends for a
factor that can't be controlled (e.g., number of people hit by
lightening), and one could say that suddenly a community is doing
dramatically worse. What would that mean? One could argue that
projecting trends for disease or conditions (e.g., obesity) highlights
consequences to make the issue more of a priority (at least when that
issue is getting worse). The focus should be on preventability, based on
what we know today. That is, "If we did everything we now know to be
effective, we could reduce the burden by X percent, taking into account
age and changes." Projections can form the basis for aspiration. Experts
can look at models, look at subtle changes over recent years, or predict
ceiling effects. Without those judgments, it is hard to frame decisions
about how targets should be set. Another value of projections is to
offer understanding of what has happened up to this point. What factors
actually caused changes? Will these factors continue?
Providing clearly defined terms. It is important to be clear in defining
terms, as past iterations of Healthy People have used terminology
inconsistently. A "stretch" target could be differentiated from an "aspirational" target because the stretch is based on limited knowledge
of what may be an effective intervention (e.g., small studies indicate
an effect). There was disagreement among members of the Committee about
the distinctions between the terms, "projection," "target," and "objective. Ultimately, Dr. Fielding noted that this controversy
underscores the importance of having standardized definitions that are
aligned with typical usage.
Choosing Aspirational vs. Practical Targets.
Aspirational targets are meant to inspire, but if the targets are not
reachable, the credibility of the effort is compromised. Aspirational
targets might be set for determinants of health because, from a health
perspective, there are no specific targets for broad goals like closing
gaps in poverty or increasing high school graduation rates. These
factors won't change based on more screening tests.
Setting Targets for Outcomes vs. Determinants. Should there be two
streams of projections: outcomes (related to behaviors, evidence based
interventions, etc.) and determinants? One view is that it's not
possible to project the socioeconomic environment. Another is that there
is no need to make projections for these issues; one could simply state
that improving determinants is important.
Reflecting on Past Target-setting Approaches. In health
planning, a great deal of energy is spent looking forward, but time is
rarely spent in looking back at targets that were ambitious and
unrealistic. There has not been a careful of analysis of what's gone
well and what's gone wrong in past target-setting efforts. The issue of
lessons learned from the past 20 years is critical.1
The Committee should recommend that the Secretary undertake a careful
review of processes that have been effective or ineffective in helping
to meet year 2000 and 2010 objectives and fully integrate those lessons
into the 2020 objective and target-setting processes.
Summarizing the discussion of target-setting, Dr. Fielding commented
that Healthy People 2020 efforts should strive to be more uniform with
previous iterations. Definitions should be consistent, and it is should
be clear in every case how objectives and target are set. Dr. Sondik
remarked that in the midcourse review of Healthy People, agencies often
talk about their programs, but there isn't a case where a program has
addressed all of the American people who may have a particular problem.
Missing from the logic of Healthy People is an understanding of how one
would go about reaching the entire country. An element of translation is
needed.
Dr. Mercer said that if Healthy People 2020 is to become a central
source for obtaining, acting upon, and providing information, it may be
difficult to respond to user needs while working under federal auspices.
When a Web site has a .gov URL, there are restrictions about what can
and cannot be put on the Website. When the CDC looked at building a
knowledge management system, static functions were allowable, but there
were challenges to providing spaces where users could interact and
learn. It may be useful to consider strategies such as funding a
parallel Web site, and admonishing users that they are leaving the
federal site.
Dr. Fielding asked the Committee members to review the draft list of
recommendations he had circulated and to comment on any needed additions
or changes. Pat Remington said there was no specific mention regarding
the need to support public health surveillance and data infrastructure
at the federal level. Dr. Fielding asked him to develop that piece.
Other issues mentioned included the needs to:
- Promote "practice-based evidence."
- More closely tie the locus and budget for public health research
to Healthy People 2020.
- Use NIH-funded studies to provide well-collected data on
populations of interest in order to document progress on health
disparities.
- Use evidence for both objective-setting and target-setting.
- Capitalize on the work that others are doing nationwide through
partnerships and collaborations.
- Produce "fast-track" reviews of the evidence.
- Incorporate the self-evident community-based interventions for
which proof is not needed (e.g., having a dentist in the community).
- Provide specific, measurable, accountable objectives in the area
of health determinants. (The WHO and local organizations offer
models.)
Data availability and mining
Dr. Fielding highlighted the importance of a robust, overarching
structure for the objectives. There should be something that increases
the kinds of information for which relatively recent data are offered,
including data about processes. There is a need for data at state and
local levels. Communities should be able to interpret the data, and
there should be a structured periodic process to review whether
objectives and targets are being reached or not, and to have that as a
feedback mechanisms for target-setting. Dr. Sondik mentioned that
another idea might be to add an annual report based on Healthy People
measures that links back to the data.
VIII. Recommendations for Healthy People Audience Aids
3:00 PM - 3:30 PM
Ideas for tools and technical assistance
Dr. Fielding asked what recommendations the Committee should make to
the Secretary about tools for different audiences. Ideas mentioned were:
user-friendly information; tutorials about how to use Healthy People;
downloadable PowerPoint presentations; and case studies. To move towards
a relational database, it will be important to understand how people
from different user groups would come to the Healthy People system. What
kinds of questions would they ask? What would be their patterns of
usage? Gaining these insights would require another stage of limited
audience research. Other ideas discussed were:
- A specific set of materials designed for faculty to help them
present Healthy People information to their students/graduate
students.
- Tools to help states and territories set objectives using the
same methods as the national level.
- Information for city health departments and community-based
organizations.
- Accurate health information about health on TV (Hollywood Health
& Society).
- Resources including links to effective interventions that have
been manualized; ways to help people understand costs; and sources
of funding.
- How to model behavior for other people and help others with
behavior change.
- Access to a community health database (already online) that
enables users to enter their locality and obtain quick comparisons.
It offers easy links if users want to map their own community.
VIII. Subcommittee on System Specifications
3:30 PM - 4:00 PM
Efforts to-date
Dr. Ronald Manderscheid, Chair of the Subcommittee on System
Specifications, explained a draft report that his group had provided to
the members. It described how HHS can make the paper version of Healthy
People 2020 electronic, and presented assumptions about how one would
design a fixed query system, with the data organized in a relational
way. Health status would be linked from proximal causes back to distal
causes. User feedback should be incorporated into the design of the
interface and system. Dr. Manderscheid asked for consensus around the
approach so that the subcommittee can complete the report.
Dr. Fielding said a downside of a relational database is that it
gives equal valence to everything, without permitting prioritization or
giving the user a way to think about it. He felt it would be important
to decide whether to organize the information in some way. Also, what
static modules might be developed? Dr. Kumanyika added that fixed
queries should be determined through a process designed to avoid having
them lead to a dead end. Dr. Manderscheid said the people who build the
relational model could design the query. Another member asked if this
report suggests using a template to anticipate the questions that a user
might ask. Dr. Manderscheid said there would be a finite set of queries
to address underlying relational models. He provided examples of queries
the system might answer.
Future Work
Dr. Manderscheid presented ideas for additional areas where the
Committee should provide phased input on: 1) a fully operational
National Public Health Information Infrastructure (NPHII) by the year
2020, and 2) a fully operational online self and community health system
by the year 2020. For the NPHII, strategic goals would include online
sharing of national, state, and county epidemiological and service data.
Other features could include fully operational online adverse event
reporting systems for biological, radiological, vaccine, and drug
incidents. For the online system, strategic goals would include
implementation of online evidence-based self and community health tools
to promote Healthy People 2020 goals.
Dr. Fielding asked for feedback on whether this was appropriate and
if so, whether the proposed approach would be the right way to go about
it. Dr. Kumanyika asked for clarification of the phasing, including what
would need to happen first, second, and third. Dr. Manderschied noted
that this important question hadn't been answered yet. Explaining the
level of effort required, Dr. Manderscheid said he thought this
subcommittee should work with federal staff to help think through the
initial steps and to give feedback on how HHS can build it. A member
asked how this fit with the report presented earlier in the
presentation; he felt this was more than the group had discussed. It did
not seem feasible for this year. Dr. Fielding said he did not hear
enthusiasm for making these issues a focus of the Committee's Phase II
work.
X. Committee Discussion: Organizing Objectives
Dr. Fielding suggested that the Committee delay talking about
specific objectives until the next day.
XI. Summary of Day 1 and Charge for Day 2
4:45 PM
Dr. Fielding asked the Committee members to look at the focus areas
for Healthy People 2010 that evening and think about what might be
changed. In addition, he asked members to think about: the subcommittees
needed for completing Phase II of the Committee's work; the products the
Committee should prepare in the coming year; and the immediate
recommendations the Committee should provide to the HHS Secretary for
actions in the coming year.
- ODPHP conducted an analysis of three objectives—access, tobacco,
and cancer— looking at target-setting methods, and whether or not the objectives had
reached their targets. Time and resource limitations prevented them from responding to the
question of "why" objectives had or had not moved toward their targets. National
objectives encompass programs well beyond HHS, so it is difficult to assess the factors
impacting final progress toward the target.
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