Report of the Tracking Network Workgroups Download as PDF [199 Kb]
Report of the Tracking Network Workgroups
- Executive Summary
- Background, Vision and Process
- Workgroup Recommendations
- Attachment A: Member Agencies and Organizations of the Tracking Workgroups
- Attachment B: Final Report (Workgroup 2)
- Attachment C: Final Report (Workgroup 3)
- Attachment D: Partnership for Integrated State Information Systems
This workgroup focused on the need for an expanded and redefined relationship between CDC and ATSDR and EPA as it relates to tracking. Although these agencies have collaborated on many issues over the years, the workgroup recognized that collaboration needs to be strengthened to ensure the success of the tracking program. EPA maintains many environmental hazard data bases at the national level and in state environmental protection agencies, and these need to be integrated with exposure and health outcome databases maintained by state public health agencies, CDC and ATSDR, and others. Additionally, interventions derived from analyses of linked data will in many cases need to be developed and implemented by both public health and environmental protection agencies.
- Representatives from CDC, ATSDR, EPA, and other partner
organizations should meet with state public health and environmental
protection officials to identify barriers to collaboration and
determine ways to remove these barriers and enhance collaboration.
- Lead tracking agencies in the states need to facilitate
collaboration among all relevant parties because responsibility for
critical health and environmental data often rests in disparate
government agencies (e.g., state fish and wildlife, agriculture, and
- Relevant local public health and environmental agencies and organizations must be partners in tracking because a substantial amount of health and environmental data are collected at the local level, and disease prevention strategies are often implemented at the local level.
CDC and ATSDR's Proposed Plan for an Environmental Public Health Tracking Network should be reviewed to determine whether it needs to be updated to reflect workgroup recommendations.
Request for Proposal (RFP) recommendations
- Both public health and environmental protection agencies should be
eligible to receive funding for tracking. Either entity can serve as
the lead tracking agency and must tangibly demonstrate interagency
collaboration through written agreements. (NOTE: After the development
of this recommendation, Congress appropriated $17.5 million to CDC in
fiscal year FY 2002 "for development and implementation of a
nationwide environmental health tracking network and capacity
development at State and local health departments." Thus, state
environmental protection agencies and other entities within states
were not eligible to apply for FY 2002 tracking funds. However,
applicants should ensure and document that appropriate collaboration
has been or will be established and maintained with state
environmental protection agencies.)
- RFPs should be tiered so that eligibility encompasses public
health agencies with existing capacity such that they can begin some
tracking activities immediately as well as agencies that propose to
develop the infrastructure to implement tracking activities.
- Essential public health and corresponding environmental functions
should be integrated into RFP requirements.
- Tracking program grantees should be given reasonable flexibility
in the hazards, exposures, and health effects their networks will
- Local agencies and organizations should be given sufficient fiscal and programmatic support to cover tracking program requirements and responsibilities. State-level grantees should be allowed to form consortia with such local agencies and organizations as necessary to further the aims of tracking activities, including the transfer of financial and other resources to such agencies.
Workgroup 2 addressed issues related to information technology and its application to data acquisition, data management, and data analyses. This workgroup's charge was to recommend ways to apply new technologies to the development of a nationwide environmental health tracking network. Because of the complexity of this workgroup's charge and the resulting length of its report, only its principle recommendations are displayed below. Reference Attachment B for the complete Workgroup 2 report.
- The EPHTN should be developed in cooperation with CDC's National
Electronic Disease Surveillance System (NEDSS), EPA's National
Environmental Information Exchange Network, and other national data
- The EPHTN should consist of a system of distributed data sources,
all of which can receive or send data. Data providers should, to the
extent possible, maintain their data at their location, in the data's
original form, in the data provider's preferred database, and in the
- The EPHTN should adopt metadata standards that allow users to find
and use data available in the network.
- EPHTN architects should work with federal partners and private
standard-setting organizations to share, create, or modify data
processing, performance, and technology standards.
- EPHTN architects should adopt a formal technology-neutral
methodology for modeling, analysis, and design of the tracking
network. This will provide both an architectural framework and
technical guideline for the surveillance facts of the diseases,
conditions, environmental hazards, and environmental exposures
relevant to the tracking network. Formal models should be developed to
encompass the business model, workflow models, partner models, process
models, use case models, options analysis models, data-flow models,
and data models.
- The EPHTN should identify, integrate, and make available tools for
data analysis, interpretation, and presentation. To the extent
possible, data dissemination should use automation tools, such that
"the data find the user" rather than forcing users to repeatedly
search for information when new updates become available.
- EPHTN architects should explore developing relationships with
private providers (e.g., physicians, administrators of health care
plans, pharmacy staff, emergency department staff, poison control
center staff, laboratory personnel) to gain access to nontraditional
surveillance and tracking data sources.
- EPHTN architects should ensure data sharing agreements exist
between relevant agencies at the state and federal levels. These
interagency agreements, or memoranda of understanding, allow agencies
that collect data under specific legal authority to release those data
to the agencies who need them for program and policy development
planning. Such agencies include state and local agencies, EPA, poison
control centers, the National Institutes of Health (NIH), the U. S.
Geologic Survey (USGS), the Department of Energy (DOE), the Department
of Housing and Urban Development (HUD), and the National Aeronautics
and Space Administration (NASA).
- EPHTN architects should develop a comprehensive information security plan and include technical specifications describing the plan in the construction of the network.
This workgroup's recommendations focus on capturing and strategically leveraging current and future opportunities. The recommendations aim to put in place the foundations necessary to develop and support environmental public health tracking. They emphasize coordinating and consulting between public health and environmental protection practitioners, linking existing tools, and sharpening a select few of the tools to better capture environmental health endpoints. At the same time, the recommendations envision the need for a successful tracking system to serve as a platform for creating the next major additions to the public health tool box, specifically through leveraging Health Insurance Portability and Accountability Act (HIPAA) standardization requirements for administrative and clinical encounter data, and renewing an appreciation for the role of public health laboratories in protecting public health and safety.
Because of the complexity of this workgroup's charge and the resulting length of its report, only its principle recommendations are displayed below. Reference Attachment C for the complete Workgroup 3 report.
- As an initial step, the EPHTN should support states to create or
build on links across health and related data sources for priority
chronic disease and environmental health endpoints. Such links may be
as simple as the co presentation of indicators for diseases and
conditions of interest in a common medium (e.g., narrative report or
geographic display), or as elaborate as fully integrated software
systems, depending upon the state's current level of sophistication.
- A demonstrated relationship between state departments of health
and state environmental protection agencies (or their appropriate
analogues) that will facilitate data linkage, interpretation, and
development should be a prerequisite for health tracking support.
Opportunities for connectivity and leverage include shared geographic
information system (GIS) platforms, interdepartmental liaisons, ATSDR
cooperative agreements, and state public health and environmental
- A) CDC, ATSDR, and EPA should establish a regular forum for
intensive, hands on (applied) exchange between state and federal
public health and environmental data developers, statisticians, and
other users. B) CDC and ATSDR should facilitate evaluation of GIS for
application to the EPHTN.
- CDC and ATSDR should enhance core chronic and environmental health
surveillance systems to better capture information about environmental
exposures and conduct state pilots as part of the EPHTN.
- Concurrently, CDC and ATSDR should improve the ability of existing
systems to capture priority health endpoints.
- CDC and ATSDR should actively and routinely survey the federal
government's planned and ongoing studies for appropriate opportunities
to integrate environmental health questions.
- Tracking programs should focus on the increasing importance of
ambulatory settings as sources of data because conditions of public
health importance are increasingly being managed in these settings.
- The EPHTN should support pilot projects to explore the trade-offs
among different approaches to capturing epidemiologic data from the
health services domain. For example, state public health officials
should be encouraged to develop relationships with health plans or
other sources of encounter data for the populations within their
- CDC and ATSDR should provide technical assistance to states in
developing data-sharing agreements based on lessons learned by other
public and private data sharing partnerships in the health services
domain (e.g., state Medicaid agencies and their contracted
managed-care plans and CDC's own collaboration with the American
Association of Health Plans and the HMO Group). CDC and ATSDR also
should ensure regular feedback from state experiences to HHS data
standards groups (including the HHS Health Data Council, the National
Center for Vital and Health Statistics, the Center for Medicare and
Medicaid Strategies, the Public Health Data Standards Consortium, and
HL-7). Finally, on the basis of states' experiences, CDC and ATSDR
should advocate within these groups for relevant variables, metrics,
and coding practices.
- CDC and ATSDR should pilot a modified "State National Health and Nutrition Examination Survey" with a smaller questionnaire and much larger sample with target oversampling.
The RFP should give highest priority to applications proposing to strengthen surveillance for one or more of the high-priority health conditions (e.g., asthma, birth defects, cancer, neurologic illnesses). Alternatively, applicants could offer the candidate condition( s) with a justification as to why it is a priority. The applicants may consider linking existing health data systems or proposing new, innovative approaches to capture the desired information. The value of proposals also should be examined regarding the impact and applications for other states. Starting with the surveillance of a selected health condition as the key element, proposals may be submitted under one of the following tiers:
|Tier||Health Surveillance: Level of Linkage|
|Tier 1: Basic||Developing and testing surveillance methodology for a given
health condition(s). Focused only on linking health data systems.
Health Surveillance Data Health Surveillance Data
|Tier 2: Enhanced||Developing and testing or using an existing surveillance
methodology for a given health condition(s) and exploring linkage
to existing human exposure (i.e., biomonitoring) or environmental
Environmental Data Biomonitoring Data
|Developing and testing surveillance methodology for a given
health condition(s) and exploring linkage to existing human
exposure (i.e., biomonitoring) and environmental data bases
Environmental Data Biomonitoring Data Surveillance Data
The tier under which a state chooses to submit a proposal is assumed to be a function of the existing capacity and capability of that state. Thus, a state with rudimentary health tracking for the priority health conditions might opt to submit a proposal that would start at Tier 1 to begin to build basic capacity and capability. Similarly, a state with fairly advanced surveillance and environmental monitoring systems would be expected to submit a Tier 2 or 3 proposal. Proposals would be competed only within tiers. The ultimate goal is for all states to have the capacity and capability to link environmental, biomonitoring, and health surveillance data bases.
Consideration also should be given to proposals that chose to strengthen primarily biomonitoring systems. The following are of special interest: metals, pesticides, volatile organic solvents, persistent bioaccumulative toxicants, and EDCs. The applicants should address the development of analytical techniques and design and pilot a sampling strategy that would reflect the exposure status for the population of the state and/or a target subpopulation (e.g., children). Again the value of a proposal could also be examined as to how broad the impact and applications would be for other states. A tiered approach is envisioned:
|Tier||Biomonitoring: Level of Linkage|
|Tier 1: Basic||Develop and test biomonitoring approach for population and subpopulation for selected class(es) of pollutants.|
|Tier 2: Enhanced||Develop and test biomonitoring approach for
population/subpopulation for a selected class(es) of pollutants.
and explore linkage to existing health surveillance or
environmental data bases
Surveillance Data Environmental Data
|Develop and test biomonitoring approach for population and
subpopulation for selected class(es) of pollutants, and explore
links to existing surveillance and environmental data bases
Environmental Data Biomonitoring Data Surveillance Data
This workgroup focused on developing recommendations that will help ensure that information developed by tracking programs will lead to effective public health actions. These actions include detecting new health events and unusual disease occurrences associated with environmental exposures, developing and implementing health policies and disease prevention strategies, monitoring and assessing the effects of these policies and prevention strategies, increasing citizen understanding of environmental health issues in their communities, and guiding research initiatives.
- Conduct focus groups of key target audiences to determine what
they want and need from an EPHTN and share that information with the
successful applicants for the pilot projects.
- Establish a system for ongoing communication between CDC and ATSDR
staff and all of the pilot program staffs. That communication should
share lessons learned and early evaluations of success.
- Hold an annual meeting for the pilot projects, the current
workgroups, and other interested parties.
- Provide a briefing of the Trust for America's Health staff once the final workgroup recommendations are consolidated. The briefing can be open to other interest groups and Congressional staff.
- Work with EPA to establish an indoor air monitoring program to
identify key environmental tracking indicators that might be linked to
critical diseases such as asthma.
- Foster state and local health departments to fully implement their
- Ensure their surveillance research agenda addresses research needs
that are identified in the pilot projects.
- Continue to encourage a community-based research model.
- Share research findings and agendas with other federal agencies,
especially EPA and the National Institute of Environmental Health
- Establish a website to provide continuously updated information on the progress of the pilot projects and the overall status of the EPHTN.
- Grant and cooperative agreement applicants should identify target
audiences in their submissions. They should further specify how they
would reach out to these groups for both planning and implementation
purposes. Audiences should include:
- The health community: federal, state, and local public health
professionals; private health-care providers; the health insurance
industry; and pharmaceutical companies
- Affected communities: people affected by environmental factors
and health outcomes, as well as advocacy groups for environmental
and health causes
- The media: TV, radio, journals, magazines, and newspapers
involved in developing and delivering messages about environmental
- Politicians: Congress, the Administration, state governors and
legislators, city and county political structures, and others
responsible for funding and legislation affecting environmental
public health tracking
- The health community: federal, state, and local public health professionals; private health-care providers; the health insurance industry; and pharmaceutical companies
- Research to determine audience wants and needs should be
undertaken at all levels (including the pilot projects).
- Partnerships should be encouraged not only with local public
health and environmental departments but also with key stakeholders
such as schools, community advocates, local health-care providers, and
local water boards. Applicants should identify specific steps for
outreach to such organizations.
- Grantees should allow full, public access to all data on the
network with the appropriate medical confidentiality caveats.
- Grantees are encouraged to use a wide variety of modes to present
their data. Graphics should be used whenever appropriate (GIS mapping
is an especially effective presentation and analytical tool). Tabular
presentations, written text (especially "story telling"), and other
methods should be also used as appropriate to the intended audience.
The instruments for data presentation should also vary. Use of the
Internet should include straight presentations, interactive standard
queries, and independent analyses. Use of print materials and CD ROM
formats should be considered as appropriate.
- Tracking pilot projects should develop a public health action
feedback loop. Surveillance should not be conducted for surveillance
purposes alone. Rather, the tracking systems should be developed with
the goal of positively affecting the public's health. Applicants
should discuss in their proposals how they will design their programs
to affect public health actions and a commitment to report on at least
an annual basis their success in meeting one or more of the following
public health actions:
- Research: how disease "clusters" and possible links to
environmental exposures were identified and research hypotheses
generated from data analysis (e.g., children's cancer clusters
possibly related to contaminated water supplies)
- Policy changes: how new health or environmental policies were
generated (e.g., requiring non arsenic-treated wood used for
- Education: how public education efforts were undertaken to
prevent future exposures to harmful environmental contamination
(e.g., school campaigns to warn students about the dangers of
playing with mercury)
- Strategic interventions and prevention: how actions were taken
by public health officials to interdict exposure or mitigate the
affects of exposure (e.g., providing alternative sources of water if
existing water supplies are found to be contaminated)
- Linkage changes: how new partnerships were developed between
organizations not traditionally associated with public health (e.g.,
forming new alliances between environmental and health agencies,
with insurance companies, or with faith-based organizations)
- Health provider training: how feedback loops were established
with local physicians informing them about disease clusters in their
communities and training them to diagnose and treat those diseases
- Legislation and Regulation: how new or additional legislation or
regulations were proposed to prevent continued exposure (e.g.,
banning smoking in public buildings)
- Research: how disease "clusters" and possible links to environmental exposures were identified and research hypotheses generated from data analysis (e.g., children's cancer clusters possibly related to contaminated water supplies)
- Pilots should be chosen on the basis of greatest potential of
success; however, some funding also should be directed for planning
and capacity building.
- The RFP should describe the EPA's National Environmental Information Exchange Network grant program and how these two programs can complement each other.
"It is clear that the U. S. needs to establish a national environmental health monitoring system which strengthens the surveillance of key health conditions in conjunction with monitoring the presence of pollutants in our bodies and the environments with which we come into contact. The recent, tragic events in the U. S. further reinforce the critical need to have access to reliable data on environmental exposure and disease outcomes. In times of crisis, the information is needed quickly and in a usable format." Source: Roundtable on Environmental Health Sciences, Institute of Medicine, The National Academies of Science, April 10-11, 2002, Background and Goals for the Workshop, Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment.
We live in an era of major threats to our health but also in an era with unprecedented opportunities to conquer these threats. These opportunities include converging federal tracking-related initiatives that have significant political and citizen support and when coupled with advances in information technology and scientific breakthroughs, can revolutionize the practice of environmental public health in terms detecting and preventing disease, clarifying the role of our environment in disease causation, and empowering citizens and communities with information about the diseases and hazards in their communities. These opportunities include:
- Bioterrorism funding to the states that will enhance overall
public health capacity and competency
- Major CDC and ATSDR tracking-related initiatives under way (in
partnership with state and local public health agencies and the
private sector) that will accelerate progress and that represent
comprehensive approaches to disease surveillance. These primarily
include the National Electronic Disease Surveillance System (NEDSS),
an electronic information system architecture for use in the states
that establishes data standards and is designed to automatically
gather health data from a variety of sources on a real-time basis; and
the eHealth Initiative, a public-private partnership addressing ways
to rapidly capture and transmit such information as emergency
department visits, diagnoses, and laboratory transactions using NEDSS.
- EPA's National Environmental Information Exchange Network, a new
nationwide initiative with the states to build locally and nationally
accessible, cohesive, and coherent environmental information systems.
The goals of this program are to improve the quality of environmental
data, provide agencies and the public ready access to these data, and
increase the ability of state agencies and EPA to employ this
information to protect public health and the environment.
- The NCEH and ATSDR Shared Vision that builds on the complementary
strengths of both agencies
- Expanded support for biomonitoring, the exposure component of the
tracking equation, both at NCEH and in the states
- Unprecedented opportunities to study gene-environment interactions
and their relation to disease causation
- The $17.5 million FY 2002 appropriation to CDC to implement pilot tracking programs in the states
The tracking workgroup process identified numerous practical and valuable recommendations. The process brought diverse disciplines to the table and resulted in the development of new and redefined professional relationships among professionals representing many tracking-related disciplines. The creativity harnessed by this process will accelerate progress toward full and effective implementation of the tracking program as envisioned by The Pew Environmental Health Commission, CDC and ATSDR, and their partners.
Implementing an environmental public health tracking program is a high priority for CDC and ATSDR and their partners because it provides a strategic opportunity to address some of the most challenging public health problems facing local, state, and national public health and environmental leaders. Its successful implementation will provide information about the possible relations between environmental exposures and chronic and other diseases that can lead to interventions to reduce the burden of theses illnesses. CDC and ATSDR and their partners have a unique and historic opportunity to implement a program that will monitor and safeguard the health of all people living in the United States.