September 18, 2007

The Honorable Michael O. Leavitt

Chairman

American Health Information Community

200 Independence Avenue, S.W.

Washington, D.C. 20201

Dear Secretary Leavitt:

The Population Health and Clinical Care Connections Workgroup (PH/CCC) encompasses a broad perspective of population health and is described using five interrelated domains: Public Health Surveillance and Response; Health Status and Disease Monitoring; Population Based Research; Population Based Clinical Care; and Health Communications/Education.

The recommendations in this document fall predominantly under the domain of Public Health Surveillance and Response. Future recommendations will be required to better address the remaining four domains. The Population Health and Clinical Care Connections Workgroup (PH/CCC) has the following broad charge:

Broad Charge for the Workgroup: Make recommendations to the Community that facilitate the flow of reliable health information among population health and clinical care systems necessary to protect and improve the public's health.

The Workgroup’s deliberations highlighted a number of key issues with respect to the broad charge:

• Public Health infrastructure at the local, state and federal levels needs to be modernized to meet current and emerging threats by increasing the flexibility, functionality, and interoperability of systems that support public health.

While public health has made progress in the last several years toward developing information systems to support program specific needs, many of these systems have followed a pattern of program specific funding that constrained the scope of the solution (e.g., HIV surveillance systems cannot be easily adapted to serve other communicable disease surveillance needs). Resulting solutions are “siloed” and unable to be scaled to large complex outbreaks and events. As evidenced in the last decade alone SARS, monkeypox, anthrax, and natural disasters such as hurricanes Katrina and Rita, public health emergencies are becoming more routine. Testimony has shown that point or targeted solutions built in response to an emergency, often relying on inexpensive and readily available technologies such as Microsoft Access and/or Microsoft Excel, scale poorly in large emergencies that require complex contact tracing, data or information sharing across jurisdictions, and cross source data linking. Robust, scalable solutions that integrate detection with investigation and response are largely unavailable to public health agencies; resulting vulnerabilities could be mitigated by thoughtful development of a strong public health infrastructure founded on interoperable systems that support routine use but are designed to scale and adapt to all hazards. A strong public health infrastructure available across all jurisdictions and levels of public health, regardless of size, will go far toward reducing the wide variation in deployment of information technology that exists in public health today.

However, before interoperable systems are developed, functional, security, and interoperability criteria must be in place. The lack of criteria for public health systems is the next key issue.

• Functional, security and interoperability criteria will establish the basis for developing flexible, information systems that can be certified for functionality to support public health activities.

Public health agencies at different jurisdictional levels have disparate business needs and different capacities. Across state and local health departments there are significant capacity disparities. Large municipal health departments may have substantially more resources than their smaller rural counterparts or than some of the smaller states, yet each are expected to provide similar services. Activities supported by information systems differ across public health jurisdictional levels. For instance, outbreak investigations are comprehensively carried out and conducted at the local or state setting, with federal assistance being requested when needed. Key functions at those levels (e.g., case triage and management, epidemiologic investigation, contact tracing and tracking of laboratory diagnostics) must be incorporated into information system solutions. All levels of public health should collaboratively define criteria for interoperable systems to effectively support public health functions.

Variable organizational responsibilities across public health jurisdictional levels complicate efforts to standardize communications. While functional requirements may differ across jurisdictional levels, common data needs exist for all levels; a key difference is in how the data are used and analyzed by each level. Data standard requirements are necessary to ensure content and transmission uniformity across organizations involved in public health. Our goal is to limit the variation in capacity across similar jurisdictional levels while promoting interoperability across all levels.

• Public health has as a goal the consistent implementation of nationally recognized data standards, common vocabulary standards and definitions, and systems available to support response.

Standards to support public health functions related to response should be prioritized for harmonization by the Health Information Technology Standards Panel (HITSP). Certification criteria should be established to evaluate software solutions for functionality that support public health. This reinforces recommendations 1.1 and 1.2 submitted to American Health Information Community (AHIC) by the PH/CCC Workgroup and accepted in March 2007.[FN1] These recommendations commit to the development of an approach, including development of additional and more detailed use cases to support standards identification and methods to measure certification criteria. There is insufficient emphasis and resources within public health to support the HITSP and certification processes to ensure there is capacity to harmonize standards and develop certification criteria for AHIC population health use cases. Software developed for public health response would need to adhere to HITSP harmonized standards, and meet certification criteria. This would promote standardized, interoperable solutions suitable for broad use and should curtail current redundant development pathways.

• The value to clinical care for including public health as an integral partner in health information technology (HIT) should be clearly articulated and widely distributed.

This issue reiterates the need for a public health business case as indicated in recommendation 1.0 of the PH/CCC March 2007 letter to AHIC[FN1]. Public health should be considered as more than just a recipient of clinical information but also as a source of information to clinical care. Clinical care provides case reports, adverse event reports and clinical data to appropriate public health entities, as well as providing updates to registries (such as immunization registries). Public health adds value to data derived from multiple sources (e.g., clinical care, veterinary, Food and Drug Administration, environmental sources), and makes this information available to clinicians to assist them in decision-making. Treatment recommendations, guidelines, assistance during vaccine shortages as well as updates to case definitions and the notifiable conditions list are examples of information provided back to clinical care.

The business case should encompass integration with clinical decision support (CDS) tools in electronic health records. The integration would not only prompt for reports to be sent to public health, but also provide clinical reminders from public health such as treatment recommendations and guidelines or vaccinations that are due. The AHIC CDS Planning Group focuses on CDS integration, and the PH/CCC Workgroup supports these and the other national efforts that exist in this space.

This letter provides both context and recommendations for how these issues can be addressed to implement informational tools and business operations to support real-time nationwide public health event monitoring and rapid response management. The overarching recommendations strive to address the key issue of strengthening the public health infrastructure. The area specific recommendations are aimed at addressing the key issues of defining criteria and standards for information systems that support public health.

BACKGROUND AND DISCUSSION

The threat of significant naturally occurring or man-made health events is a critical issue for the nation. Once an event has been detected, the ability to manage the event, determine the appropriate response, quickly mobilize resources and administer countermeasures can save lives.

The real-time nationwide public health event monitoring and rapid response management is addressed through four underlying priority areas. These priority areas were defined and ranked by the Workgroup based on an iterative process in 2006. The prioritization was followed by a visioning exercise to baseline the current state, and establish mid-state (by 2010) and end-state (2014 and beyond) visions for each priority area. After Biosurveillance, the PH/CCC Workgroup defined and recommended the implementation order for the following priority areas:

1. Case Reporting

2. Bi-directional Communications

3. Response Management

4. Adverse Events Reporting

Recommendations in the priority areas of Case Reporting and Bi-directional Communications were made to AHIC in March, 2007. The Workgroup then turned deliberations to the priority area of Response Management. The recommendations in this letter are based on Workgroup input, and informed by testimony given on March 29th and June 15th, 2007. Testimony and the resulting recommendations focus on four interrelated aspects of response management:

1. Outbreak and event management

2. Laboratory response

3. Countermeasure allocation, tracking, distribution and administration

4. Automated integration with registries

The overarching recommendations and the recommendations in the four aspects of response management are aimed at addressing the key issues described in this letter. As stated earlier, the key issue around a business case for data/information exchange between public health and clinical carehas been covered in the March 2007 recommendation letter.

These current recommendations seek to increase the adoption and modernize public health information systems by making them fully functional (certified), and interoperable (standards compliant), in order to support the business processes required by local (~ 3000), state and territorial (~ 57) and federal (CDC and other) governmental public health authoritities.

RECOMMENDATIONS:

1. Overarching

The overarching recommendations are divided into two areas. The first targets improvements in infrastructure by developing informatics expertise in the public health workforce. The PH/CCC Workgroup endorses the effort to train 1,000 public health informaticians by 2010 and provide informatics leadership training to an additional 1,000 public health executives. The Workgroup endorses the concept of and placement of chief public health informatics officers in each state health department.

The second recommendation provides clarification for, and endorses use of, preparedness and other funds for building infrastructure in public health agencies and labs. This recommendation strives to move away from funding by program function, which has exacerbated the diversity seen in existing systems, and move toward an informatics capacity by building modular systems that adhere to common interface specifications. Both recommendations seek to close the disconnect between information technology and public health program areas that has contributed to the inadequate infrastructure issue facing public health today.

Recommendation 1.0: The Centers for Disease Control and Prevention (CDC), in collaboration with the American Medical Informatics Association (AMIA) and the Public Health Data Standards Consortium (PHDSC), and working with Schools of Public Health and other informatics fellowship programs, should enhance and promote the public health domain of the AMIA 10X10 initiative, the Partnership for Workforce Public Health Informatics Training, and similar programs to advance public health informatics workforce development. The public health informatics competencies developed by the University of Washington and CDC, and other applicable work, should be used as a basis for this initiative.

Recommendation 1.1: HHS should work with the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), the Centers for Medicare and Medicaid Services (CMS) and other federal agencies to include language in contracts, grants and cooperative agreements that ensures:

• Funds from a variety of programs can contribute to an informatics capacity and technical architecture that invests in advancing information systems and IT infrastructure required to support their implementation and interoperability. This language should explicitly include systems and infrastructure that support public health labs, registries, surveillance systems, outbreak management and response systems, as well as other systems that receive data used for population health purposes.

• In order to meet the requirements of the Executive Order: Promoting Quality and Efficient Health Care in Federal Government Administered or Sponsored Health Care Programs[FN2], funds can be used for technical support, to cover the cost of on-going system maintenance, and for updates and enhancements to provide functionality and adhere with interoperability specifications.

• Metrics should be collaboratively developed with state and local public health partners to assess the ability of public health information systems to interoperate and support public health investigation and response. These metrics should measure and monitor interoperability, usability, flexibility, quality, completeness and timeliness of data, as well as system functionality to support:

  • Outbreak and event management.

  • Countermeasure allocation, tracking, distribution and administration.

  • Integration of laboratory information.

  • Bi-directional exchange of data across clinical care and public health.

2. Outbreak and Event Management

Outbreaks vary in size and complexity, and can extend across local jurisdictions, state lines, and national borders. The SARS outbreak in Toronto[FN3] and the monkeypox[FN4] response in the U.S. illustrate the need to have systems with the ability to identify and triage suspected cases; collect initial clinical, demographic and laboratory data on suspected cases; support laboratory diagnosis, both in the clinical and public health laboratory sectors; collect relevant epidemiologic data to identify important common exposures (such as places, persons, gatherings, conveyances, or vectors) and support contact tracing and infection control, including: tracing, monitoring and possible quarantine of individuals exposed to a person with a communicable disease. Systems must be in place to manage complex relationships between cases, contacts and potential exposures. Methods for real-time tracking of these linkages should provide public health authorities with the ability to know who to investigate, manage, offer prophylaxis, isolate, quarantine, and/or treat.

Testimony to the PH/CCC Workgroup expressed a common theme: systems to support outbreak and event management are needed for use by public health. Criteria for these systems should be defined collaboratively, and the solutions should be both flexible and scalable to be used routinely and during emergencies. A freely distributable version of outbreak and event management software that integrates well across jurisdictions should be made available for use by public health departments.

Recommendation 2.0: By March 2008, the Centers for Disease Control and Prevention (CDC) with the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the Council of State and Territorial Epidemiologists (CSTE), the Association of Public Health Laboratories (APHL) and other appropriate groups, should update and refine criteria for functionality, security and interoperability of systems that support outbreak management at local, tribal, state and federal levels. The criteria should:

• Be minimal but sufficient to support the needs of managing complex outbreaks.

• Ensure interoperability with other systems (such as other outbreak systems, laboratory information systems (LIS), systems that manage countermeasures, fatality management tracking systems, monitoring tools for quarantine and isolation, electronic health records (EHRs), and surveillance databases).

• Provide a starting point for a freely distributable software implementation and ongoing development and maintenance.

• Use as a starting point the AHIC Use Cases, the HITSP Interoperability Specifications, and the PHIN Functional Requirements for Outbreak Management.

Recommendation 2.1: The Centers for Disease Control and Prevention (CDC), with input and assistance from state and local public health should support the development and testing of software systems designed to manage public health investigations (e.g., CDC Outbreak Management System, state or commercially-developed systems), including identification of important exposures, laboratory diagnostics, contact tracing and indication for preventive countermeasures such as infection control, isolation, quarantine, prophylaxis or treatment.

• With HHS, and through the national agenda, support the harmonization of standards and the development of implementation guidance and shared architectural approaches for possible and confirmed case management and exchange. These products should be made available to public health partners by October 2008.

• Develop, or commission the development or acquisition of, a freely distributable software; and support the maintenance and implementation to assist local, tribal, state and national agencies in the management of outbreaks. The criteria for this software implementation would be based on the collaboratively defined criteria defined in recommendation 2.0 above. This software should be available no later than March 2009.

• By December 2009, support the establishment of test sites to measure the level of interoperability between electronic health records, laboratory information systems, surveillance and software developed for outbreak management.

3. Laboratory Response

Laboratory testing plays an important role in multiple domains related to this report including Public Health Surveillance and Response, Health Status and Disease Monitoring and Population Based Clinical Care. While much attention has been placed on electronic laboratory reporting for notifiable diseases (ELR), the full breadth of laboratory testing from which actionable information can be derived extends to other processes associated with laboratory testing, including requests for testing services and physician orders. The ability to electronically exchange test orders and test results facilitates multiple functions, including the rapid identification of outbreaks of disease, the monitoring of the health of a population and the generation of data essential for response to a public health event and ongoing situational awareness. Testimony illustrated that during an outbreak or event, laboratory test volume can dramatically escalate, requiring the test loads be balanced among laboratories in different jurisdictions. This was observed during the anthrax events of 2001 when the Laboratory Response Network (LRN)[FN5] laboratories tested over 125,000 samples representing over 1 million separate laboratory tests. The reporting, aggregation, and analysis of the results from the many labs performing the testing was complex and unsupported by electronic exchange between organizations involved in the response. Significant human effort was required to consolidate and reconcile data, activities that can be largely eliminated through adoption of standard approaches to electronic laboratory test ordering and reporting. The anthrax events, followed by SARS and more recently the numerous food borne outbreaks (E. coli in spinach, salmonella in peanut butter) illustrate the need to develop and broadly adopt common specifications and processes to enable specimen and results tracking and corroboration among public and private laboratories and public health partners. Infectious diseases are not the only challenges facing public health laboratories. Following the impact of Hurricane Katrina, laboratory services provided by the Louisiana Public Health Laboratory had to be shifted to other distant sites including the Iowa State Hygienic Laboratory. The testimony not only called attention to the need for collaboration among labs and public health partners, but also the need for federal agencies to coordinate and harmonize requirements across the entire United States.

Coordination of reporting requirements from clinical, veterinary, environmental and public health laboratories to state and federal agencies would reduce the current reporting burden on labs and clear the path to define standards and vocabulary for automated exchange of test results. In June 2005, the Department of Homeland Security established the Integrated Consortium of Laboratory Networks (ICLN) with a Memorandum of Agreement to promote harmonization and coordination across multiple laboratory networks affiliated with federal agencies (LRN-B, LRN-C, NAHLN, FERN, eLRN, etc.). The ICLN includes 10 federal departments/agencies, including Agriculture, Commerce, Defense, Energy, Health and Human Services, Homeland Security, Interior, Justice, State, and the Environmental Protection Agency. The ICLN’s mission is to create a U.S. homeland security infrastructure with a coordinated operational system of laboratory networks that provide timely, high quality, and interpretable results for early detection and effective consequence management of acts of terrorism and other events requiring an integrated laboratory response. The PH/CCC Workgroup recommends support of the interagency coordination efforts of the ICLN.

While federal agencies play an important role in confirmation and investigation of disease outbreaks or public heath events, the majority of sentinel data is generated either within the community laboratory or the local or state public health laboratory. The lack of uniform process and standards significantly hinders the ability of federal agencies to coordinate the response effort and limits efforts at the local and state levels to share information efficiently. Therefore, a significant need exists to harmonize data reporting standards and guidelines among local, state and federal agencies. Testimony addresses significant progress being accomplished by the CDC and APHL in pilot projects directed toward achieving a uniform approach to electronic exchange of laboratory test orders and results reporting. The PH/CCC Workgroup recommends the expansion of these efforts with the goal of achieving an integrated laboratory system focused on public health.

To achieve these collective goals, the Workgroup further recommends:

Recommendation 3.0: By June 2008, the Centers for Disease Control and Prevention (CDC), in collaboration with the Association of Public Health Laboratories (APHL), the Council of State and Territorial Epidemiologists (CSTE), the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), and other appropriate organizations, should identify any types of data, codes and relationships needed (beyond those specified in the HITSP EHR / Biosurveillance lab result message) necessary to support:

• Test orders to and result reporting from public health labs.

• The coding of public health conditions in the HITSP lab message.

• Result reporting of veterinary and environmental data.

• Unambiguous linkage of laboratory data to clinical and public health records.

The scope of this effort should be inclusive of the additional public health laboratory response requirements not included in the AHIC EHR Laboratory and Biosurveillance Use Cases (e.g., orders and results for veterinary, environmental and food specimens). This effort should include, at a minimum, the AHIC Minimum Biosurveillance Data Set (MBDS) and the HITSP lab result message interoperability specification as well as the planned HITSP additions. An analysis should be done to identify possible additional domain vocabularies to support the expanded scope for public health laboratory response. The CDC should identify new priorities from this work and advance them through the PH/CCC Workgroup for incorporation into the national agenda process.

Recommendation 3.1: HHS, in conjunction with state and regional health information exchanges, public health and clinical laboratories, should develop the infrastructure and architecture for unambiguous unique identification of medical service providers in association with the Nationwide Health Information Network (NHIN) initiative. This should include ensuring that registries of medical service providers exist and that registry lookup capability is developed and available to laboratories for routing laboratory data back to the originating requestor, and to other appropriate parties, to support national electronic laboratory data exchange.

Recommendation 3.2: By December 2008, HHS, in collaboration with the Association of Public Health Laboratories (APHL), private laboratories, and other federal laboratories, should establish regional or national capabilities to receive and route laboratory results to all appropriate recipients simultaneously.

• Define the processes and approaches for consolidated receipt and routing of laboratory results.

• Support a proof-of-concept demonstrating an efficient regional or national mechanism for the acquisition of laboratory test order information as well as dissemination of test results to appropriate public health and clinical care providers.

4. Countermeasure Allocation, Tracking, Distribution and Administration

Response Management includes interventions (i.e., isolation and quarantine) as well as acquisition and allocation of supportive countermeasures (e.g., treatments, prophylaxis, and provisions) during a public health response. Tracking activities include monitoring shortages and apportioning countermeasures during a shortage, administration management, distribution of resources, and coordination of potential assets through the commercial sector supply chain.

Some of the same issues exist in the area of countermeasures, as noted in other public health activities:

• Standards are currently incomplete or not available to support countermeasure needs across jurisdictional units. Standards should include a set of uniform minimum data elements, common vocabulary and defined relationships between the data elements; operational guidance to include system redundancy, security, and reliability; and should consider methods to handle materiel identification, such as bar coding standards.

• Information on the availability of countermeasures in the commercial supply chain is, at times, considered to be sensitive and proprietary information of commercial organizations; not readily sharable with public health.

• While countermeasure distribution systems are available for tracking and follow-up, they are not well-integrated. There are few commercial off-the-shelf (COTS) products available to support countermeasure administration and follow-up.

• Customization of a COTS product can be cost prohibitive and still not guarantee that the final product will meet the organization’s requirements nor interoperate with other jurisdictions or vendor resources.

• Hospitals have developed and implemented electronic tracking systems that do not interoperate with public health resources or informational needs. During testimony, specific local health departments mentioned limited capacities to fund interfacing with community providers and partners as it would detract from capacity to provide ongoing public health services.

• Legal concerns persist regarding provision of clinical data (e.g., hospital system data) to public health officials for active surveillance.

• There is a need for obtaining as much information as possible during an outbreak or event so that you know what materials are available, who has them, and where the greatest need exists.

• Information gaps exist in the supply chain; for example, information doesn’t come back from treatment centers to Point of Distribution (POD) sites.

Because outbreaks and events are not limit to jurisdictional boundaries, systems must interconnect both horizontally and vertically. During a response, secure exchange between the private sector and public health may be needed across jurisdictions and national borders. To be effective, this requires comparable growth toward integration and interoperability in both public health and the private sector -- a need which the AHIC process strives to fulfill. Although it is recognized that data needs to be exchanged across jurisdictions during an emergency, it is also important to recognize that data must be shared on a routine basis. In 2004, 14% of the population moved domiciles at least once. In addition, annually there is a significant portion of the population that changes domiciles on a temporal basis, such as college students and “snowbirds.”

Recommendation 4.0: By March 2008, the Centers for Disease Control and Prevention (CDC) with the Association of State and Territorial Health Officials (ASTHO), the National Association of County and City Health Officials (NACCHO), the Council of State and Territorial Epidemiologists (CSTE), the Association of Public Health Laboratories (APHL), the Food and Drug Administration (FDA), and other appropriate groups, should update and refine criteria for functionality, security and interoperability of systems that support countermeasure apportionment, tracking, distribution and administration at local, tribal, state and federal levels. The criteria should:

• Be minimal, but sufficient to support the needs of managing countermeasures during a response.

• Ensure systems are interoperable with other systems (such as outbreak systems, vendor managed inventories, point of distribution software, fatality management tracking systems, monitoring tools for quarantine and isolation electronic health records, and surveillance databases).

• Provide a starting point for a freely distributable software implementation, and ongoing development and maintenance.

• Use as a starting point the AHIC Use Cases, the HITSP Interoperability Specifications, and the PHIN Functional Requirements for Countermeasure Response and Administration.

Recommendation 4.1: By April 2008, the Centers for Disease Control and Prevention (CDC) should convene a meeting to include representation from clinical partners, manufacturers, and distributors to understand the resources that are available in the private sector and develop strategies to exchange information on the availability of and demand for resources at any given time.

Recommendation 4.2: The Centers for Disease Control and Prevention (CDC), with HHS, and through the national agenda, should support the harmonization of standards and development of implementation guidance and shared architectural approaches for the exchange of countermeasure information. These products should be made available to public health partners by December 2008. Following the implementation of countermeasure response solutions, support the establishment of test sites to measure the level of interoperability with electronic health records, outbreak management systems, registries, surveillance systems.

Recommendation 4.3: By June, 2008, HHS should facilitate development of national administrative or legal approaches for routine and emergency inter-state data exchange of countermeasure and immunization information.

• Address business propriety data concerns of relevant commercial supply chain entities.

• Develop a blanket agreement to provide federal support for sharing of data and resources when it is necessary.

• Communicate with and educate hospital risk management staff and privacy and confidentiality officers in clinical care settings to alleviate concerns about public health access to clinical data.

5. Automated Integration with Registries

During a response, registries may be used for multiple purposes, and the potential for additional uses should be explored. Registries of emergency response volunteers, credentialing, and those responders with appropriate immunization status may be used to identify personnel prepared to participate in a response. Similarly, during a response, registries may be used to track people given countermeasures, being monitored (e.g., quarantine) and those requiring long-term follow-up. Immunization registries played a key role after hurricanes Katrina and Rita in providing vaccination records for displaced children; saving an estimated $4.6 million dollars in potential revaccination costs[FN6]. During deliberations, the Workgroup recognized that health information exchanges (HIEs) may eventually assume some of the functions currently handled through integration with registries. The Workgroup identified that a powerful role may be possible for HIEs in the future, and this may be an area to prioritize for future deliberations. However, this section is focused on recommendations for registries.

In the area of immunization registries, the infrastructure for these systems, known as Immunization Information Systems (IIS), is partially established. The IIS information infrastructure is in place in a number of states and includes characteristics that should be endorsed and extended. In general, registry systems should be population-based and adopt industry standards-based techniques for data communication.

Capabilities developed in more established registries, such as the infrastructure of IIS and the clinical data exchange of cancer registries, could be leveraged to improve integration with both clinical and public health registries during a response. The first step is to facilitate dialog to discover short-term and long-term benefits that could be realized from automating integration with registries. The second step is to prioritize potential advances, and communicate efficiencies that could be realized with the appropriate parties.

Recommendation 5.0: By March 2008, the Centers for Disease Control and Prevention (CDC) should convene a group of public health registry experts such as immunization, cancer, trauma, donor, chronic disease, and others to determine how the established capabilities and unique attributes of existing registries could be used in public health response.

Recommendation 5.1: By October 2008, the Centers for Disease Control and Prevention (CDC) should develop a communication plan based on discussion and recommendations from the March 2008 meeting referenced in recommendation 5.0 above. The overall goal of this plan is to communicate to public health officials the available registry resources for use during an emergency response.